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OBSTETRICAL TRANSACTIONS 



VOL. XXIII. 



TRANSACTIONS 



OBSTETKICAL SOCIETY 



LONDON. 

VOL. XXIII. 

FOR THE YEAR 1881. 

WITH A LIST OF OPFICBHS, PISLLOWS, KK. 






LONDON : 

L0N0MAN8, GEEES, AKD CO. 

1682. 



PRINTED BT J. B. ▲DLABD* BABTHOLOaCBW CLOBB. 



■■■1 


^^^^^^~^^^^^^^^^^^^^^^^^^^^^^^^^^^| 


OBSTE 


rRICAL SOCIETY OF LONDON. ^ 


OFFICERS FOR 1SS2. ^^^^| 


HOKOBA.RT 
PBKSIDBKT. 


Elictkd Fehruakv ^^^^^^I 


FAEEE, ARTHUR, M.D., F.E.S. ^^^ 


PBKBIDMT. 


DUNCAN, J. MATTHEWS, M.D., F.R.S.Ed. 1 




f BASSETT, JOHN, M.D. (Birmingham). M 




BRUNTON, JOHN. M.D. ■ 




GODSON. CLEMENT, M.D. ■ 


PBEaiDENTS. 


HUTCHINSON, JONATHAN, F.B.C.S. ■ 


THOKliURN, JOHN, M.D, (Manchester). ■ 




WILLIAMS, JOHN, M.D. ■ 


IBBABDBEE. 


POTTER, JOHN BAPTISTE, M D. ■ 


HOMOKA.Br 


GALABIN, ALFKED LEWIS. M.A., M.D. ■ 


■scBBTABres. I HERMAN, GEORGE KRNE.ST, M.B. ^ 


HONOBAUT 


CHAMPNETS, FRANCIS HENRY, M.A.,M.B. 




■ OLDHAM, HENRY, M.D. (P-t iV™. and Tn.^ee). 




BARNES, ROBERT, M.D. (Pa.* iV«. and 3V«(«). 




DAVIS, JOHN HALL, M.D. 


HOVOBi^BT 


HEWITT, GRAILY, M.D. 


UEUBBBB 


HICKS, JOHN BRAXTON, M.D.. F.R.8. 


OF COUBCIt. 


PRIESTLEY, WILLIAM 0,, M.D. 




TILT, EDWARD JOHN, M.D. 




WELLS, THOS. SPENCER, F.H.C.S. (Trustee). 




■-PLAYFAIB, WILLIAM 8,, M.D. 




''ANDERSON, JOHN FORD, M.D. 




ANDREWS, HENRY CHARLES, M.D. 




BATE, GEORGE PADDOCK, M.D. 




BENNET, HENRY, M.D. (Weybridge). 




BURCHELL, PETER LODWICK, M.B. 




CARTER, CHARLES HENRY, M.D. 




CHARLES. T. EDMONDSTOUNE, M.D. (Cal- 




cutta). 


OTUER 


MALINS, EDWARD, M.D. (Birmingham). 


UEUBESa 


HIGDEN, WALTER. 


9F COUNCIL. 


HOBERTS.DAVID LLOYD, M.D.(Manche8ter). 




SALZMANN, FREDERICK WM. (Briehtonl. 




8EWELL. CHARLES BRODIE, M.D. 




STEPHENSON, WILLIAM, M D. (Aberdeen). 




STRANGE, WILLIAM HEATH, M.D. 




TAYLOE, EDWARD. 




THORNTON, JOHN KNOAVSLEY, MB., CM. 




WALLACE, FREDERICK. 


^ 


YARROW, GEORGE EUGENE, M.D. 



LIST OF PAST PRESIDENTS OF THE 

SOCIETY. 



1869 EDWARD RIGBT, M.D. 

1861 WILLIAM TTLEE SMITH, M.D. 

1863 HENEY OLDHAM, M.D. 

1866 EGBERT BARNES, M.D. 

1867 JOHN HALL DAVIS, M.D. 
1869 GRAILT HEWITT, M.D. 

1871 JOHN BRAXTON HICKS, M.D., F.RS. 

1878 EDWARD JOHN TILT, M.D. 

1876 WILLIAM OVEREND PRIESTLEY, M.D. 

1877 CHARLES WEST, M.D. 

1879 WILLIAM S. PLAYFAIR, M.D. 



FOR THE YEAft 1882 

Appointed by the Council. 



AVELINQ, JAMES H.. M,D. 

BARNES, KOBERT, M.D. 

BARNES, R. S. FANCOURT, M.D. 

BLACK, JAMES WATT, M.D. 

BOULTON, PERCY, M.D. 

DUNCAN. JAMES MATTHEWS. M.D.. F.R.S. Ed. 

EDIS, ARTHUR W., M.D. 

GERVIS, HENRY. M.D. 

GODSON, CLEMENT. M.D. 

HEWirr. GRAILY, M.D. 

HICKS, JOHN BRAXTON. M.D., F.R.S. 

LEISHMAN, WILLIAM, M.D.. Glasgow. 

MALINS, EDWARD, M.D.» Birmingham. 

PLAYFAIR, WILLIAM S., M.D. 

POTTER, JOHN BAPTISTE, M.D. 

ROBERTS. DAVID LLOYD, M.D., Manchester. 

ROPER, GEORGE. M.D. 

SAVAGE, HENRY, M.D. 

SCOTT, JOHN, F.R.C.S. 

SQUIRE, WILLIAM. M.D. 

SWAYNE, JOSEPH GRIFFITHS, M.D., Clifton. 

THORBURN, JOHN, M.D., Manchenter. 

THORNTON, J. KNOWSLEY. M.B., CM. 

WELLS, T. SPENCER, F.RX.S, 

WILLIAMS, JOHN, M.D. 



STANDING C0MMITTEES7 



BOAKD FOR THE EXAMINATION OF MIDWIVES. 



cnAiBMAN. AYELINfl, JAMES H., M.D. 

BARNES, R. 8. FANCOUBT, M.D. 
BUUNTON, JOHN. M D. 
GODSON, CLEMENT, M.D. 
WILLIAMS. JOHN, M.D. 
f OALABIN, ALFRED LEWIS, M.D., Hon. See. 
• I HERMjVN, GEORGE E., M.B., Ron. See. 



M-OFFICIO. ■ 



LIBRARY COMMITTEE. 



EX-OFFICIO.- 



AVELING. JAMES H., M.D. 
BARNES, R. 8. FANCOURT, M.D. 
BARNES, ROBERT, M.D, 
EDIS, ARTHUR W., M.D. 
POTTER, JOHN BAPTISTE, M.D. 
WILLIAMS, JOHN, M.D. 
DUNCAN, JAS. MATTHEWS, M.D., President. 
GERVIS, HENRY, M.D., Treaiurer. 
GALABIN, ALFRED LEWIS, M.D.. 
HERMAN, GEORGE E., M.B., 
CHAMPNETS, FRANCIS HENRY, M.A.,M.B., 
Hon. Lib. 



> Son. Sect. 



COMMITTEE FOR THE COLLECTION OF 
SPECIMENS OF PELVES, ETC. 



BAENES, EGBERT. M.D. 

BASSETT, JOHN, M.D., BirmiDgham. 

BLACK, JAMES WATT, M.D. 

BRANFOOT, ARTHUR MUDGE, M.D., 
Madraa. 

BURZORJEE, BURZORJEE DORABJEE, 
Bombay. 

GRIMSDALE. THOMAS F., L.E.C.P. Ed„ 
Liverpool. 

HATES, THOMAS C, M.D. 

HEADLEY, WALTER BALLS, Melbourne. 

KIDD, GEORGE H., M.D., DubJip. 

LEISHMAN, WILLIAM, M.D., Ghsgow. 

McCALLUM, DUNCAN CH^iRLES, M.D., 
Mod treat. 

PERRIGO, JAMES, M.D., Montreal. 

POTTER, JOHN BAPTISTE. M.D. 

PRICE. WILLIAM NICHOLSON, Leeds. 

ROBERTS, DAVID LLOYD, M.D., Man- 
chester. 

SAVAGE, HENRY, M.D. 

8WAYNE, JOSEPH GRIFFITHS, M.D.. 
Briatol. 
r DUNCAN, J. MATTHEWS, M.D., President. 
\ QALABIN,ALFREDLEWIS,M.D.,Z/on.Seo. 
I. HERMAN GEORGE E., M.B.JZfon. See. 
i, M.D. J 



} SMITH, HEYWOOD, ] 



HONORARY LOCAL SECRETARIES. 



JoNBs, Evan Aherdare. 

Baetrum, John S., F.R.C.S Bmh. 

CoERY, Thomas C. S., M.D Belfast. 

Berry, Saucbl, Esq., F.R.C.S Birmingham. 

Salzuann, Fuedgrick William Brighton. 

SwAYNE, Joseph Griffiths, M.D Bristol. 

Carlyle, David, M.D Carlisle. 

Jeffco AT, James Henry Chalbam. 

Roper, Alfred Geobqe Croydon, 

Baker, John Weight Derby. 

Macneilaqe, David, L.B.C.P.Ed Durham. 

Batten, BaynerW., M.D Gloucesler, 

Clark, James Fenn Leamington. 

Braithwaitb, Jambs, M.D .. Leeds. 

Wallace, John, M.D Liverpool. 

Robert^, David Lloyd, M.D Manchester. 

Elder, Georbe, M.B., CM. NottingliBoi. 

Walker, Thomas James, M.D Feterborongli. 

Eyelby, Joseph Frederick, L.B.C.P Plymooth. 

HarrinsoN, Isaac, Esq., F.R.C.S Readiug. 

Wilson, Robert James, F.R.C.P. Ed St. Leonard's. 

Cross, Richard, M.D Scarborough. 

Jackson, Edward, M.B Sheffield. 

BUKD, Edward, M.D. , CM Shrewsbury. 

Murphy, James, M.D Sunderland. 

Fowler. James Wakefield. 

Butler, Febdkeick John, M.D Winchester, 

Harris, William John Worthing. 

Harvey, Robket, M.D Calcutta. 

Branfoot, Aethce Mtidbb, M.D. Madras. 

Fktherston, Gerald H., M.D Melbourne, Australia. 

pEBRioo, James, M.D Montreal, Canada. 

Trmple, James Alobenon, M.D Toronto, Canada West. 

Anderson, Ikett W., M.D Jamaica. 

Takaki, Kanaheiro, F.R.C.S Japan. 



OBSfETRIOAL SOCIETY OF LONDON. 



TBUflTXSS or THB SOCIETY'S PROPERTt. 

Hbnuy Oldham, M.D, 
Robert Baknbs, M.D. 
Thomas Spknceh Wells. 



HONORARY FELLOWS. 

BRITISH SUBJECTS. 

Elteted 

1862 Duncan, James Matthews, M.D., A.M., LL.D., F.R.S.Ed., 
Physician -Accoucheur to, and Lecturer on Midwifery 
and Diaeaiea of Women and Children at, St. Bnrtholo- 
mew's Hospital ; 71, Brook street, GrosveDor square, 
W. Council, 1878-80. Pres. 1881-82. 

1870 Fabke, Arttiub, M.D., F.R.S. (Hon. Pbes,), Physician- 

Accoucheur to H.R.H. the Princess of Wales; 18, 
Albert Mansions, Victoria street, Westminster. 

1871 Keilleb, Aleiandeb, M.B., F.R.S, Ed., Physician to the 

Royal Maternity Hospital, Lecturer on Midwifery and 
Diseases of Women and Children at Surgeons' Hall, 
Edinburgh ; 21, Queen Street, Edinburgh. 
1871 EiDD, Georoe H., M.D., F.R.C.S.L, Obstetrical Surgeon 
to the Coombe Lying-in Hospital, aud Examiner in 
Midwifery at the Queen's University and Royal College 
of Surgeons of Ireland; 30, Merrion square sooth, 
Dublin. 



n 


ORDINAKY FELLOWS. ^^^H 


Th 


^^^^1 






innuil lubacriptiaiiB. ^H 


Tlifl 1e 

Elect 


Ion O.F. are proHiod to the ntmei of tlii " Originil Fellowi " of the ^| 
Sodetj. ^M 


H 


1869 


AsAUB, Thomas Ruthebfokd, M.D., Surgeon to the ^M 




CroydoD General Hospital 1 Stamfard House, St. James's ^M 




road, West CroydoD, 8. H 


1879 


Aduis, PniLii>, L.R.C.P. Ed., Iver, Bucks. ^M 


1859 


ALDEB8EY, Willkm Hugh, M.B. Loud., F.R.C.S., 37, St. 1 




Andrew's Square, Surbiton. 


1871 


Alderson, Frederick H., M,D., Southerton House, Glen- 




thorue road. Hammersmith, W. 


1878 


Albbed, Henhy Allen, M.D., 4, Westboume park, W. 


1876 


Alfoed, Fbedbb:ck Stephen, 61, Haveratock hill, N.W. 


1873 


Allen. Henet Makcus. M.R.C.P. Ed.. 38, Regency 




square, Brighton. 


1859 


Ahsden, Oeouqe John, M.D., Holly Lodge, Crawley, 




Sussex. 


1878 


Andebson, Izett William, M.D., 92, HanoTet street. 




Kiogstoi), Jamaica. Hon. Loc. See. 


1875 


Anderson, John Fobd, M.D.,C.M.,28, Buckland crescent, 




Belsiie park, N.W. Council, 1882. 


1366 


Akobews, Henry Chablkb, M.D., 1, Oakley square, N.W. 


K 


Couueil, 1882. 


■ 1S59 


Andrews, James, M.D., 149, Camden road, N.W. Couneil. 


■ 


1881. 


■ 1870 


Appleton, Robekt Caklisle, Toll Garel, Beverley. 


1 





PELLOWB OF THE SOCIETY. SV 

Elected 

ISa9 Abcbeb, John, F.R.C.S., 9, Carpenter rond, Edgbaston, 
BirmiDgham. 

1871 Aroles, Fbake, L.R.C.P. EJ., Hermon Lodge, Wflnstead, 

Essex, N.E. 

18(i 1 ABH9TR0NO, JouN, M.D., OreeD street green, Dartford, Kent. 

O.F. Atelinq, James H., M.D,, Physician to the Cbelsea Hospital 
for Women ; I, Upper Wimpole Street, W. Council, 
1865-66, 1872. Hon. Sec. 1873. Bon. Lib. IS74-6. 
nee-Prei. 1877-8. 

1872 Ailing, Aktrub H. W., 94a, Great Portland atreet, W. 
1859 Aylino, WiLLiAU HBNBr,L.R.C.P. Ed., 103,Great?ortIand 

street, W. 
1880 Bailey, pKAKcttt Jamss, 51, Orove Street, Liverpool. 

1873 Bailey, James Johnson, M.D., L.R.C.P. Bd., Hill Crest, 

Marple, Cheshire. 
1877 Bakbb, Albert de Winteb, 2, Lawn terrace, DawUih, 

1876 Bakek, John Penninq, 6, York place, Fortmao square, W. 
1859 Bakes, John Wbioht, Surgeon to the Derbjsiiire General 

luGrmary; 102, Friar gate, Derb]r. Council, 1879-80. 

Bon. Local Sec. 
1880 BaLLb-Headley, tee Headley (Balis). 
O.F. Bankisteb, Joun Henby, 436, Oxford atreet, W. 
1869 Bantock, Geobqe Gbanville, M.D., Surgeon to tlie 

Samaritan Free Hospitnl ; 12, Granville place, Portman 

square, W. Council, 1874-6. 

1874 Bakbeb, Edwabd, 259, Gloeeop road, Sheffield. 
1874 Barclay, John. M.D., 10, Low street, BaufF. 

O.F. Baknes. Eobebt, M.D., F.R.C.P,, Obstetric Phyaiciaa to 
and Iiccturer on Midwifery at, St. George's Hospital; 
IS, Harley street, Cavendish square, W. Fiee-Pret. 
1859-60. Council. 1861-62, 1867. Treat. 1863-C4. 
Pre: 1865-66. Truttee. 



FIDLLOWS OF THE SOCIETY, 



1B71 
1871 



1871 

1880 



Barnes, R. S. FiNCOiniT, M.D., PbyaicUn to the British 
and GenercJ Lying-in Hospitals ; AesiBtant Physician to 
tbe Royal Maternity Charity; Obstetric Physician 
to the St. George's and St. James's Dispenaary; 7. 
Queen Anne street, Gaveudisb square, W. Council, 
1879-81. 

Babnes, Thomas Henry, M.D., hi, London road, Croy- 
don, S. 

BiBBATT, JoaEPU G., M.D., 8, Cleveland gardens, Bays- 
water, W. 

Bartrdk, John S., F.H.C.S., Surgeon to tbe Batb General 
Hospital; 13, Gay street, Bath. Bon. Lot. See, 
Council, 1877-9. 

Ba83ETT, JotiN, M.D., Professor of Midwifery at the Queen's 
College, Birmiughaia ; 144, Hockley Hill, Birmingham. 
Council, 1874-6. Fict-Fiei. 1880-2. 

Bate, George Paddock, M.D., L.R.C.P. Ed., 41^>. Bethnal 
Green road, E; and 2, Northumberland Houses, King 
Edward road. Hackney. Council, 1882. 

Batten, Raynek W., M.D., Physician to tbe Qlouceater 
General Inlirmary; 1, Brunswick square, Gloucester. 
HoH. Loc, Sec, 

Beaoh, Fletoueb, M.B., Darenth Asylum, Dartford, Kent. 

BEADLEa, Abthub, Park House, 1 1, Park rond terrace, Forest 
hill, S.E. 

Belchek, Henry, M.D., L.K.C.P. Ed.; 12, Pavibon 
parade, Brighton. 

Bell, Robeut, M.D. Glasg., 29, Lyuedoch atreet, Glasgow. 

Beninqton, Robert CitEVFDsaN, Rosebank, Copleston road, 
East Diilwich. 

Bgnnet, Jambb IIenbt. M.D,, Tbe Ferns, Weybridge, and 
Meutone. Council, 1881-2, 

Bbbry, Saueel, F.R.C.8., Consulting Surgeon-Aecoucheur 
to the Queen's Hospital, and Professor of Midwifery 
and the Diseases of Women and Cbildreu iu the 
Queen's CoUege ; 4, Cavendish gardens. Cavendish road, 
Clapbam common, S.W. Vice-Preii. 1859. lion. Loc, 
Sec. 



FELL0W3 OF THE SOCIETY. 



SlecUd 
1879 BtGGS, 



, 6, SunnyBide villaB, Child's kill, Headon, 



1878 BiNDON, Wm. John Veeieker, M.D., F.R.C.S. Ed., 2, Elm 

YillflB, Kilburn, N.W. 
1868 Black, Jameb Watt, M.D., Obstetric Phyaician to thu 

Cbaring Cross Hospital ; 13, ClnrgeB Btrcet, Piccadilly, 

W. Council, 187-J.-1. 
1880 Black, Robebt Francis. L.R.C.P. Ed., Eiaminer in Mid- 

vifery, Trinidad Medical Board ; 4, Chacon street. Port 

of Spain, Trinidad. 
1861* Blake, Thohas William, HurHtbourne, Bournemoutb, 

Hants. 
1872 Bland, Geobge, Surgeon to the Macclcslield luGrmary ; 

Park Green, Macclesfield. 
1866 Blease, Thomas, Clairville, Altriucham, Chesbire. 
1868 Boggs, Alexander, M.D., late of U.M.'s Madras Armv 

362, Bue St. Ilonoi^, Paris. 

1879 BoNNOB, William Jambs, 56, Maury Road, Stoke Newing- 

lon, N. 

1872 Bo3WORTH, John Routledge, Sutton, Surrey. 

1866 BoULToN, Percy, M.D., PlivBician to the Samarit&n 7ree 
Hospital ; Obstetric Physician to Out-PatientB, Queen 
Charlotte's Lying-in Hospital ; 6, Seymour street, Port- 
man square, W. Council, 1878-80. 

1877 BowKETT, Thomas Edwabu, 145, East India Road, Poplar, 



1869 BoTD, Herbert, Sui^on-Major, 14th Sikbi [agents, 
Henry S. King and Co., 4.5, Pall MsB]. 

1877 Bradley, Michael McWelliams, M.B., Jarrow-on-Tyne. 
, 1873 Bbaithwaite, James, M.D„ Lecturer on Midwifery and 
Diseases or Women and Children at tbe Leeds School ot 
Medicine ; Assistant Sut^eon to tbe Leeds Hoapitnl for 
Women and Children; 16, Clarendon road, Little Wood- 
house, Leeds. Fiee-Pret. 1877-9. Hon. Loe. See. 

VOL, XXIII. b 



ELLOWS OF THE 80CIETV. 



Hhcted 
1S62 



BiiAiTHWAiTE, William, M.D., Ute Lecturer on Midwiifery, 
Leeds ScLool of Ketliciue; ClarendoD House, 20, Cla- 
rendon road, LeeUB. Council, 1869-70. 

BiiANroor, Abtiicr Mosge, M.D., Fsiitheoii roRd, Madrss. 
lion. hoc. See. 

BnAHTHnAiTE, HARRiaoN, F.R.C.S, Ed., Weatbury house, 
WiUeaden, N.W. 

Brewek, Alexander Hampton, 201, Queeu's road, 
Dalaton, E. 

Brickwell, John, Saw bridge worth, Herts. 

BRioawATEu, Thomas, M.B., Harrow-on-tlie-Hill, N.W. 

Bright, John Meaburn, M.D., The Glen, Forest hill, 
Sydenham, S.E. Council, \873-74. 

Brisbane, Jaues, M.D., 21, Park ro»d. Regent's park, 
N.W. 

BuocKUAN, Edward Forster, A ssi a tan t- Surgeon, General 
Hoapilnl, JlaJraa, and Professor of Pathology, Madras 
Medical College. [Per Messrs. Richnrdaon and Co., 
East India Array Agency, 13, Pall Mall, S.W.] 

BaiiDiK, George 6., M.D., Consulting Physician -Accoucheur 
to Queen Charlotte's Ljing-in lloapiud; 3, CheaUrfield 
street, Mayfair, W. Council, 1873-75. 

Bkoorhouse, Charles Toeing, M.D,, 43, Manor road. 
New CroHi, S.E. 

Bbooks, Jou Edwin, L.R.C.P. Ed., 54, Mill street, Lud- 
low, Salop. 

Brown, Andrew, L.R.C.P. Ed., Elton villa, Bartholomew 
road, Kentish town, N.W. 

Brown, D. Dvce, M.D., 29, Seymour Street, Portman 
square, W. 
187S Beown, George, 3, Gibson aquare, hlington. 
1866 Bhown, OBonnE Dransfield, Henley »Ula, Uxbridge road, 

Ealing, Middlesex. 
IS78 Browning, Benjamin, 70, Union road, Rolherbitbe. 
1880 EEtoK, Robert, 70, Old street, St. Luke's, E.C. 
1576 Brunjes, Martin, 27, Edgeware road, W. 



1878 

1875 

1862 
18/2 
1864 



1871 



I8G6 



1876 



1878 



1868 



1865 



JJl. 



BauNTON, John, M.D., 
Mflteniily CliarUy; 
)871-3. fice-Prei. 



I. A., Surgeon to the Royal 
, EuBtoQ roBcl, N.W. Council, 



1863 Brvant, Tuomas, F.R.C.S., Surgeon to Guy's HoapiUl; 

53, Upper Brook itreet, W. Council, 1866-67. 
OT. BtttANT, Walter John, F.H.C.S., M.R.C.P. Ed., 23i, 

Susaei square, Hyde park gardens, W. Council, 1859. 
1870 Buck, Joseph Handle, L.R.C.P. Ed., 26, Sidbury, Wor- 

1878 Buncombe, J. Pobree, Prfitre Meintyea Fontein, Beaufort 
West, Extension Railway, Cape Colony. 

1861 BcNNY, Joseph, M.D., Hon, Surgeon to the Newbury Dia- 

pensary ; Korthbrook atreet, Newbury, Berks. 
1877 BuscRELL, Peter Lodwick, M.B., Surgeon- Accoucheur 
to the City of London Lyiug-iu Hospital ; 2, Kingsland 
road, E. Council, 1882. 

1877 BcBD, Edwabb, M.D., M.C, Senior Physician to ihe Salop 

In6rmary j Newport House, Shrewsbury. Hon. Loe. 
See. 

1878 Burn, Stacev Southeedon, Richmond, Surrey. 

1862 BnuTON, John Moulden, F.R.C.S., Lee park lodge, Lee, 

Kent, S.E. Council, 18«8-69. 
1878 Burton, William, L.H.C.F. Ed,, 79, New North road, 
Hoi ton, N. 

1864 BtTLEB, Frederick John, M.D., Surgeon to Wincbeater 
College and St. Cross Hospital, and to the Hanta 
County Hospital, Wincheater. //on. Loc. See. 

BoTT, WiLLiAK Fhederick, L.R.C.P. Lond., 25 Park 
street, Park lane, W. Council, 1876-7». 

[ 1861 Candlish, Eekri, M.D., Physician to ihe Alnwick In- 
6rmary; 26, Fenkle street, Alnwick, Northumberland. 

I 1861 Candk, John, M.D., Surgeon -Major, Army Medical Depart- 
menl. Station Hospital, Portland. [Messrs. Wm. 
Watson & Co., Anglo-Indian Ageucy, 27, Leadeuball 
street, E.C.] 3, Prospect place, Portland, and Station 
Hospital, Portland. 



i OP THE SOCIETY. 



1872 Cablbss, Edward Nicholls, M.B., CM., LRnsdowne 

grove, DeTizes. Wilts. 
1863 Cablyle, David, M.D., 2, The Crescent, Catllale. Hon. 

Loc. Sec. 
1872 Carter, CHARtES Henrt, M.D., Physician to the Hospital 
for Women ; 45, Great Camberland place, Hyde Park, 
W. Council, 1880-2. 

Carver, EtaTACB John, Fairlawn, Fulham, 

Caskie, John Boyd, M.D., 89, Goawell road, E.G. 

Caskie, William Aley., M.A., M.B., Manse Court, 17, 
Main Etreet, Large, Ayrshire, N. B. 

Causton, William IIbnrt, 1, Pomona place, Hammer- 
smith. 

Gayzeb, Tboua9, Majrfleld, Aigburtfa, Liverpool. 

Cbaffeks, Edward, F.R.C.S., 54, North street, Keighley, 
Yorkshire. 

Ohaluers, John, M.D., 43, Caledonian road, N. 

Chambbrb, Thomas, F.E.C.P. Ed., F.B.C.S. Ed., Senior 
Physician to the CheUea Hospital for Women, Consult- 
ing Pliysician Accoucheur to the Western Maternity ; 
64, Chester square, S.W. Council, 1874-6. 

Champnevb, Fbancis Henrv, M.A., M.B.Oxon., Assistant 
OhBtetric Physiciau to St. George's Hospital, 60, Great 
Cumberland place, W. Coun«7, 1880-1. ifon. Li6.l882. 

Chance. Edward John, F.R.CS., Surgeon to the Metro- 
politan Free Hospital and City Orthopeedic Hospital ; 
5y, Old Broad street. City, E.G. 

Chakles, T. Edmondstodne, M.D., Professor of Midwifery 
at the Calcutta Medical College, 10, Harrington street, 
Calcutta. Council, 1882. 

CnABiEswottTH, James, 25, Birch terrace, Hanley, Stafford, 
shire. 

Child, Edwin Venhah, New Maiden, Kiogston-on-Tbamea, 
Sorrej. 



1877 
18C9 
1878 



1873 
1864 



FELLOWS OF THE SOCIETY. XXI 

Bleelad 

Ii363* Chiuholm, Edwin, M.D., Abergddie, Aabfield, near Sydney, 

New South Wales. [Per Meaars. Turner and Hen- 

deraon, care of Meaars, \V. Dawson, 121, Cannon 

street, E.C.]. 
1879 Cburchu.l, Alex. Febsier, M.B., Surgeon-Major, V Lines, 

South Camp, Alderahot. 
1859 Claeemont, Claddb Clabkk, Millbrook Houae, 1, Hamp- 

sleiid road, N.W. 
1859 Clabk, James Fekn, Clent Louae, Beaucbamp square, 

Leamington. Uun. toe See. 
1874 Clark, James UENur, L.R..C.P. Ed.. Gosclien Post-offiee, 

St. Eluabetb, Jamaica. [Per J. W. Goodinge, 16, 

Alderagate street, E.G.] 
1879 Clarke, Reqit^ald, South Lodge, Lee park, Lee, S.B, 
1872 Clabke, William Michell, Ute Surgeon to the British 

Geuerftl Hospital ; 2, Vork buildings, Clifton, Briatol. 
O.K. Clat, Charles, M.D., late Lecturer on Midwifery and 

Clinical Medicine in St. Mary's Hospital, Manchester ; 

Audenshaw Lodge, Audeuabaw ; and 101, Piccadilly, 

Manchester. Council, 1803-65. 
1876 Clat, Geouoe Lanosfobd, West View, 443, Moaeley 

road, Birmingham. 
O.F. Clay, John, Professor of Midwifery, Qneen's College, Bir- 
mingham ; Allan Houae, Sleelhouae lane, Birmingham. 

Covncil, 1868-69. Fice-Pret. 1872-4. 
O.F. Cletrlani), William Fredebick, M.D., Stuart villa, 

199, Maida vale, W. Council, 1863-64. Fict-Pre: 

1875-77. 
1861 Clooo, Stefiien, Looe, R.3.O., Cornwall. 
1881 Close, James Alex, M.B., L.R.C.P. Ed., Summerfield, St. 

CtuirCo., lUiuois, U.S.A. 
1865* CoATua, Cbakles, M.D., Pbyaician to the Bath General 

and Royal United Hospitals ; lU, Circus Bath. 
1859 COCKELL, Frederick Epoab, 144, Amherst road. Hack- 



ney, 



N.E 



SXII TELLOWS OP THE SOCIETY, 

Elected 

1878 CocKBLL, Fbedbriok EuQiR, Juo., 171, Richraond i 

Dalston, E. 
1875 CoFFiK, Richard Jas. Maitland, F.R.C.P, Ed., Alwiagton 

bouse, Baron's court, West Kenaington, W. 

1878 Coffin, Thomas Walkeh, B1, Queen's crescent. Haver- 

stock hill, N.W. 

1875 Cole, Richakd Bevehlv, M.D. Jeiferson Coll. Philad., 

San Frnnciaco, California, U.S. 

1876 Coleman, Matthew Owes, M.D., 5, Victoria terrace, 

Surbiton, Surrey. 

1877 CoLMAN, Waltbh Tawell. Hon. Surgeon to the Brighton 

Hospital for Women ; 87, Buckingham road, Brighton. 

1866 Coombs. James, M.D., Bedford. 

1873 CoopEK, Frank W,, LeytonBtone, Essei. 

187-1 CooPEH, HEiiifEBT, L.R.C.P. Ed., 3, Roaslyn terrace, 
Harapslead, N.W. 

1861 CooPEH, John, M.R.C.P. Ed„ Clapham rise, S.W. 

1875 CoKDEs, Aitfi., M.D., PcofesHor of Obstetrics at the Univer- 
eity of Oeueva ; 8, Corrntcrie, Geneva. 

1866 CoENWALL, James, F.R.C.S., Fairford, Gloucestershire. 

1860 Corby, Thomas Charles Steuart, M.D., Senior Surgeon 
to the lielfnst General Dispensary ; 14C, Donegall Pass, 
Belfast. Council, 1867. Hon. Loe. Sec. 

1859 CouY, FiiEDEKiCK CiiARLES, M.D., Portland villa, Buck- 
hurst liill, Essex. Council, 1867-69. 

1875 Conr, Robert, U.D., AssiataDt Obitctric Physician to St. 

Thomas's Hospital ; 73, Lambeth Palace road, 8.E. 
Council, 1879-81. 

1879 Cowan, Geobgb Hoyle, M.B., Napanee, Ontario, Canada. 
Cox, Richard, L.R.C.P. Ed., Thesle, near Reading. 

1877 Crawford, James, L.K.Q.C.P.I., Ightham, SeveDoakg. 
1881 Ckeast. James Gideon, Brasted, Sevenoaks, Kent. 

1876 Ceew, John, Higham Ferrers, Northamptonshire. 

1859 Cboft, J. McGricor A. T., M.D., M.R.C.P., 15, Abbey 
road, St. John's Wood, N.W. 



I.B. Caut., Kepton, near liui 



rCLLOWB OF THE SOCIETY. SXlll 

EUcled 

1866 Ceokt, Robket CiiAaLEs, L.R.C.P. Ed , 204, Camden road, 

N.W. 
1874 Crombib, Charles MvNN, M.B. & CM,, 10, Union terrace, 

Aberdeeu. 
16SL Cbonk, Hebbebt George, 

toa-on -Trent. 
I860 Csosa, Riciukd, M.D., 6, Queen etreet, and Carlton House, 

Belmont road, Scarborougli, Yorkshire. Hon. Loc. Sec. 

Council, 1880-1. 
196!) Ckoss, Rubeut SnACKLECOUD, PeteraHeld, Hanta. 

1867 CiioccUKR, Henb*, West Hill, Dartlord. Kent. 

1875* CuLLiNQwoiiTH, Chahlics James, Surgeon lo St. Mark's 

Hospital, Manchester; 260, Oxford road, Manchester. 
18o9 CuLPEPKB, William Moe, 1, Bruuawiclc terrace, Palace 

gardens, Kensington, W. 
1862 CuHitEBBATCH, Lawrencs Trent, M.D., 35, Cadogan 

place, Belgrave square, S.W. Council, 1868-70. Ftce- 

Pre*., 1878. 
1667 CroLAHAK, Hnou, M.D., 9, Orange road, Bermondsey, S.E. 
1659 CusGEMVGN, J. fiKE.s'uoN, II, Craven hiU gardens, Baya- 

water, W. Council, 1870-72. 

1868 Daly, Frederick Ueney, M.D., 18,'), Anihurat road, 

Hackney Uowna, N.E. Council, 1877-9. 

1876 Davies. Gomer, L.R.C.P. Ed., 66, Pembridge vilias. Bays- 
water, W, 

1878 Davies, Henry Nauston, Glyn Rhondda House, Cyinei, 
Pontypridd, GlamorgaQshire. 

O.F. Datis, John Hall, M,D., F.B.C.F., Obaletric Physician 
to, and Lecturer on Midwifery and Uiseasea of Women 
And Children at, the Middlesex Hospital; Physician 
to the Royal Maternity Ciiarity ; Consulling Physician- 
Accoucheur to the St. Pancras IniirmRry i '37, Gluuces- 
(er place, Porttnan square, W., and -11, Boundary rnad, 
N.W. Council, 1859, 1864-65. Tice-Pret. 1861-63. 
PfM, 1867-68. 





Of TUB ^^^^^^1 


^H Elected ^^^H 
^H 1863 DAYI3, Robert Albx., M.D.. St. Micbaers Vi!1m, Trent ^M 
^H Valley Boad, Licli&eld, StnfTord. | 


^f 


Davison, Francis, L.R.C.P. Ed., Saffi, Morocco, 


H 


Davson, Smite Houston, M.D., Camilea villa, 203, Maida 
Tale, W. 


H 1878 
V 1880 


Day, Edmund Oveehan, Houae Surgeon to the Royal In- 
firmary for Children, and Women, Waterloo Bridge road. 

Day, William Hankem, Surgeon to the City Priaons, 
Norwich; All Sainta' Green, Norwich. 


I85D 


Dav, Williaw Henuy, M.D., Physician to the Samaritan 
Free Hoepital for Women and Children; 10, Man- 
cheater square, W. Covncil, 1873-75. 


■ 1877 


Dban, Maeshall M. p., M.D., Keeue, Ontario, Canada. 


H 1S72 
V 1877 


Dbnton, Geohqe Bagstek, Surgeon to the Ladiea' Charity 
and Lyiog-in Hoapital; 2, Abercrom by aqu are, Liver- 
pool. 

Dewab, John, L.R.C.P. Ed., 132, Sloane street, S.W. 


ISGO 


Dickenson, John, F.R.C.S,, Hon. Surgeon to the Wrexham 
Infirmary ; Wrexham, Denbighshire. 


1879 


Ddlan, Thoius Michael, L.R.C.P. Ed., 32, North parade, 
Halifax. 


1877 


Donovan, John Island, M.D., Skibbereen, Co. Cork. 


K 1879 


DoEAN, Alban H. G., F.R.C.S., Surgeon to Out-Patienta. 
Samaritan Free Hospital ; 50, Seymour atreet, Port- 


^1 1860 


DoWNES, Denis Sidney, 55, Kentish town road, N.W. 


H 


Deaoe, Charles, M.D.. Hatfield, Herta. Council. 1861-4. 


H 1876 


Deing, WiLLiiM Ernest, L.R.C.P. Ed., Boughton-under- 
Blean, Faversham, Kent. 


H 


DcNCAN, James, M.B., 8. Henrietta street, Covent garden, 
W.C. Council, 1873-74. 


^M 1U7I 


Eabtes, Geouge, M.B., F.R.C.S., Surgeon-Accoucheur lo 
llie Western General Dispensary ; 69, Connaugbt street, 
Hyde park square, W. Council, 1878-80. 




I. . 



FELLOWS OV THE SOCIETY. 



19, Norfoli CrcBcent, Hyde park, W. 



Elee/ed 

1866 EA3T0K-, John, M.D., 
Council, 18/6. 
Eaton, John Chaubeblin, Anciuter, GrRntbam, Lincoln- 

Eddowes, William, Surgeon to tbe SaloplDfirmitry.S.Tfae 

College, Shrewsbury. 
Edi8, Aktuur W., M.D., AeBistaat-PbyaiciHD-Accoucheur 

to tlie Middteeex HoBpiial ; 22, Wimpole atreel, W. 

Council, 1873-74. Hon. See. 1874-77. Vice-Pret. 

1878-80. 
Eldeii, Geoboe, M.B., CM., Surgeon to tbe HoBpital for 

Womeo, NottinghBDi ; 17, Bege at street, Notliagham. 

Hon. Loe, Sec. 
Elkington,AbthdbOuy, Surgeon-Major, Grenadier Guards, 

b2, GilliDgham street, Eccleston square, S.W. 
Elleey, RicniUD, L.R.C.P. Ed., Plympton, Devon. 
Enoelmann, Geoiige Julius, A.M., M.D., 30U3, Locust 

street, St. Louis, Missouri, U.S. 
EvEBSHED, Chables L., Maltravers street, Arundel, Sussex. 
1875 EwABT, John Henry, Surgeon to St. Mnry'a Iloapital for 

Women and Cliildreuj LimeSeld House, Cbeetbam 

hill, Manchester. 
Eyelet, JoaEPH Feedebick, L.H.C.P. Loud., 5, Hill-park 

crescent, Plymouth, Hon. Loc. See. 
Farncombe, Richabd, 40, Belgrare street, Balsall beatb, 

BirmiDgbBm. 
Fabquuab, William, M.D., Sui^eon-Major, Uadraa Army, 

Bangalore, Madras Presidency. 
Fabb, Geo. F,, L.R.C.P. Ed., Slade House, 175, Ken- 

oingtoD road, S.E. 
Fabbeb, Geoboe Albebt, Spring Tills, Brighouae, Halifax. 
Faybeb, Sir Joseph, M.D., K.C.S.I., Hon. Physician to 

H.M. tbe Queen and to H.H.H. the Prince of Wales; 

Physician to H.R.H.tbe Duke of Edinburgh -, President, 

Medical Board, India Office, &c.; 53, Wimpole street, 

Cavcudisb square. 



1878 



1877 



1867 



1879 



1879 



1878 
J 873 



1879 



1875 



1676 



1869 



1879 



' THE SOCIETY. 



Elected 

1668 



, Chnrlton park tertM*, Old 



I.D., F.R.C.S 



, Tweed brae 



, M.D. ; Hon. Phytidan to Uie 
HoBpiUl, PrahniD, Melbourne, 



Fl£QAN, RlCHAKD, M.D., 

Cliarllon, Kent. 
Fergusson, Alesandeb, 1 

House, Peebleii, N.B. 
Fetherstom, Gehald H, 

Melbourne Lying-in 

Victoria. Hon. hoc. 
Finegas, JAMF.a Herbkrt, M.D., Obstetric Surgeon to, and 

Lecturer on Midwifery at, the Liverpool Lying-iti 

Hospital ; 4H, Rodney street, Liverpool. 
iBER, John MooaE, M.D., 2, Balmoral terrace, AnlaUy 

road, Hull. 
Fletcher, Edward, Lygou street, Carlton, Melbourne, 

Victoria. 
Flint, Arthiib, L.R.C.P., Weatgate-on-Sen, Isle of Thanet. 
1877* FoNMAKTiN, Hbsry db, M.D., Knapliill, Woking, Surrey. 
1877* Ford, James, M.D., Eltbam, Kent. 

FowLEE, James, F.S.A,, Hon. Surgeon to the Clayton Hos- 

pitnl and Wakefield General Dispcnsnry ; 13, South 

Parade. Wakefield. Conned, 1872-4. Uim. Loe. See. 
Fox, CoRKELiua Benjamin, M.D., Highfield Road, Ilfra- 

combe. 
Fbain, Joseph, M.D., Hon. Surgeon to tbe South Shielda 

Dispeuanry ; Frederick street. South Shields. 
Fraser, Angus, M.D., Pbysicinu and Lecturer on Clinical 

Medicine to the Aberdeen Royal Infirmary ; 232, Union 

street, Aberdeen. 
Feebman, Hekrv W., 2-1, Circus, Bath. 
1881 Fbodbham, JonN Mill, M.D., Denhara House, Upper 

Strealham. 
1880 Far, John Blount, Swindon, Wiltshire. 
1867 Fdller, Cuables C, 33, Albany street. Regent's park. N.W, 
' Galabin, Alfhro Lewis, M.A., M.D., AsststHnt Obstetric 

Physician to, and Joint Lecturer on Midwifery at, Guy's 

Hospital ; 14, St. Thotnae'i street, Southwark, 8.E. 

Council, lf*76-78. //on. , 



1872 



1861 



1873 



1870 



1808 



1878 



1865 



tSGfi 



1862 



1867 



I87-1* 



Lib. I8r!l, Um.Sec. I 



PELLUWS OF TUB SOCIETV. XXVll 

IBUeled 
p 1863 Galton, John H., M.D., Wootliide road, Upper Norwood, 

S,B. Counrit, 187-1-6. 
I 1881 Ganuy, William, Hill Top. Gipay hiU, S,E. 
I 1879 Gakdneb, John Twinauk, 6, HUlaboro' terrace, Ilfracombe. 
I 1872 Gardnee, W., M.A.,M.D., 551, St. Joseph street, Montreal, 

Canada. 

I 1863 Garhan, Hekhv Vincent, Kent House, 6, Bow road, E. 
I 1876 Gabneb, John, 52, New Hall street, Birmingham. 
1879 GAB3TANG, Thomas W, Habropp, Oakleigh, Dobcross, near 

Manchester. 
1873 Gakton, WiLLliM, M.B., F.R.C.S., Hsrdalmw street, St. 

Helen's, Lancashire. 
1859 Gaskoin, George, 7, Weatbounie park, W. Council, 
18/0.72. 
, 1875 Gawith, J. Jackson, 23, Westbourne park terrace, W. 
I 1S77 Obu., Thouas Silvesteb, M.D., St. John's Lodge, Kenaal 
green, W. 

1859 Gehvis, Henry, M,D., F.U.C.P., Obstetric Physician to, 
and Lecturer upon Obstetric Medicine at, St. Thomas's 
Hospital ; Examiner in Obstetric Medicine at the Uni- 
tersily of London ; 4(1, Harley street. Cavendish square, 
Couneil. 1864-66. Hon. See. 1867-70. Fiee-Pret. 
1871-3. Treat. 1878-81. 
f 1866 Gebvis, Fredkbick Heudebodhck, 1, Fellows road, 
Uaveratock hill, N.W. Council. 1877-9. 
Itf75 GiBBiNOS, Alfred Thomas, M.D., 93, Richmond road, 

Dalaton, N.E. 
187-1 Gibson, James Edwabd, Hillside, West Cowee, lele of 

Wight. 

1866 GiDDiNQB, William Kitto, L.R.C.P. Ed., Shaftesbury 

House, Calverley, near Leeds, Yorkshire. 

I 1877 Giffaed, DoccLAa William, 44, Old Steyne. Brighton. 

Itl75 Giles, Peter Broome, L.R.CP. Ed., The Quinta, Brohury, 

Hereford. 

[ 18G9 Gill, William, L.U.CP, Loud., 11, Russell square, W.C. 



XXVlll FKLLOWS OF THB SOCIETY, 

Elected 

1867 GiTTiNa, John, L.R.C.P. Ed., St. Olave'a Union, 

atreet, Soutbwark, 134, Tooley street, S.E. 
1871 GoDDARD, Eugene, L.E.C.P. Lond., North Lyone, High- 
bury New Park, N. 

1876 GoDFRAY, Alfred Charles, M.B., '13, La Motte street, 

1877 Godson, Chableb, F.B.C.S., 1, Astwood road, Cromwell 

road, Soutli EenaingtoD, S.W. 
1871 Godson, Clement, M.D., CM., ConauUing Physician to the 
City of Loudon Lying-in Hospital; Assiaiaiit Phyaician- 
Accouclieur to St. Bsrtholomew's Hospital ; 9, Groa- 
»enor alreet, W, Council, 1876-77. Son. See. 1878- 
81. Vice Pre*. 1882. 

1868 Godwin, Asuton, M.D., 28, Brompton crescent, Brompton, 

S.W. 
1873 Goldsmith, John, M.D., Highworth House, Worthing, 

1873 GooncHiLD, Nathaniel, L.R.C.P. Ed., 9, llighgate road, 

N.W. 
18G9 Goss, Tbeoeska Biddulph, 36, The Paragon, Bath. 
187.i Gray, Jamks, M.D., 15, Newton terrBce, Glangow. 

1874 Greene, Wjlliam Thouas, M.D., Moira House, Peckham 

rye, S.E. Councit, 1880. 
1863 Okiffitu, G, dk GoRRECtUER, Physician to the Hospital for 
Women and Children, Pimlico ; Physician- Accoucheur 
to St. Sa?iour'B Maternity ; 9, Lupus street, St. George'i 
square, S.W. 

1869 GBiFfiTH, John T., M.D., Talfourd House, Camberwell, 

S.E. 

1879 Griffith, Walter Spbncek Anderson, F.R.C.S.,A88isUint 

Demonstrator of Anatomy, St. Bartholomew'e Hospital ; 
64, Guilford street, Russell square, W,C, 

1880 Griffiths, Griffith, Brynedyn, Pontardawe, Swansea 

Valley. 

1870 Grigg, William Chapman, M.D., Physician to tbe In* 

patients. Queen Charlotte's Lying-iu Hospital; Assistant 
Obstetric Physician to the Westminster Hospital; 
Assistant -Physician to the Victoria Hospital for Chil- 
dren ; 6, Curzon street, Mayfair. Giuncil, 1875-77. 



PELLOW8 or rae socikty. xxix 

Eleeled 

O.F. GEiMaDALB,TH03. F., L.B.C.P. Ed., Consulting Surgeon to 

tbe Lyiog-ia Hospital, and late Lecturer on Disease* 

of Cliildren, &c., at the Boyal InfirniHry School of 

Medicine j 29, Rodney street, LiTerpool. Council, 

1861-62. Tice-PrM. 1875.76, 
1S80 Grogono, Walter Atkiks, 216, High Street, Stratford, E. 
1877 GaosHOLZ, Frederick Hermann Vaklev, L.K.Q.C.P.I., 

Pier House. Aberdovey, Merioneth a hire. North Wales, 
1876 Qeoth, Ernst E. G., M.D., 5. Weymouth street, Portland 

place, W. 
1679 Grove, WiLLiAUBicnABD, M.D., St. Ives, Huntingdonshire. 
1867 Hadaway, Jameb, L.B.C.P. Ed., 47b, Welbeck street. 

Cavendish square, W. 
I8?fi Hadden, John, M.D., 31, West atreet, Horncastle, Lincoln- 

• 1681 Hair, Jahes, M.D., Westgate, Peterborough. 
1659 Hall, Fredbbick, 1, Jermyn street, St, James's, S.W. 

' 1871 Hallowes, Fsedehick B., Redhill, Beigate, Surrey. 

I Hahes, George Henry, F.B.C.S., 7, Coburg place, Ken- 
sington gardens, W. 
Hamilton, Thomas, M.D., 30, Northampton park, Canon- 
bury. 
1874 Hannan, Fkancis John, M.B., Avouside, Downton, Wilts. 

, 1860 Hardey, Key, Surgeon to the West City Dispeusary ; 4, 
Wardrobe place. Doctors' Commons, B.C. 

[ 1872 Habdino, William, F.E.C.S.. 4, Percy street, Bedford 
square, W.C. 

1 1877 Harper, Gerald S., 5, Hertford street, May Fair, W. 

I O.K. Harper, Philip H,, F.R.C.S., 30, Cambridge street. Hyde 
park, W. 

} 1878 Haeriks, Thomas Daties, F.R.C.S., 36, North Parade, 
Aberyslwitb, Cardiganshire. 

I O.F. Harrinson, Isaac, F.R.C.S., Castle street, Reading, Berks. 
Couneil, 1H62.65. Eon.Loe.See. 

I 1862 Harris, Charles, M.D„ Natthiam, Ashford, Kent. 



XXX FELLOWS OF THE SOCIETY. 

Elected 

1872 HAHRI3, Henht, M.D., F,R.C.S.,Treng«eath place, Redrolh 

Coruwall. 
1867 Harris. William H., M.D., Professor of Midwifery id the 

MndntB Medical College, and Superintendent of the 

Lyirg.in Hospital, Madras ; 78, Oiford gardens. W. 

[agent : Mr. H. K. Lewis, Gower street]. 
1861 Hakris, William John, 26, Muine Parade, Worthing. 

Hon. Loe. See. 
1880 Harrison, Richard Charlton, ■!, The Terrace, St. Marj'a 

vale, Chatham. 

1879 IlARVEr, George, L.R.C.P. Ed., Wirksworth, Derbyshire. 

1880 Haevky, John Stephenson, 2G, Eue Wissocq, Boulagne- 

sur-Mer, France. 
1865 Haktey, Robert, M.D., .52, Chowringhee, Calcutta. 
[Per Messrs. Cochran and Anderson, 152, Union 
street, Aberdeen.] Hon. hoc. Sec. * 

1873 Hatiierly, Henry Reginald, L.R.C.P. Ed., Wellington 

street. Park side, Nottingham. 

1865 Hayes, Hawkesley Rocue, Basingstoke, Hants. 

1873 Hayes, Thomas Crawford, M.D., Assistant Obstetric Phy- 
sician to King's College Hospital; 17> Clarges atreel, 
Piccadilly, W. Cotincil, 187G-78. 

1880 Headley, Walter Balls, M.D., 190, Collins street East, 
Melbourne, Victoria. 

1880 Heath, William Lenton, M.B., St. Bartholomew's Hoa- 

pital, E.G. 
1867 Hembrodgh, John William, Ivy cottage, Waltham, 

Grimsby, 
1870 Henderson, Alexander, 2, Meadow Bank place, Rose vale, 

Partick, Glasgow. 
1878 Henry, Louis, M.D., Melbonrne. Victoria, Australia [per 

J. Kilpalriek, Esq., 2, Northampton Square, Clerken- 

well, E.C.]. 

1881 Hepburn, William Aibx., Rosslyn House, Coxhoe, Co. 

Durham. 



FELLOWS UP THE SOCIETY. 



1H76 Hesua) 



Georob Ernest, M.B., Aisistfint Obstetric Phy- 
sician to tlie London IIoBpital, 7, West street, Finabury 
circus, E.C. Council, 18/8-79. Hon. Lib. 18lf(0.|. 
Jlon. Sec. 1882. 

Hewitt, Gkaily. M.D., F.R.C.P., Professor of Midwifery 
in University College, London, and Obstetric Phyiicisu 
to University College Hospital; 36, Berkeley square, 
W. Bon. Sec. 18.^9-64, Treat. 1865-66. Fice-Pret. 
1867-68. Pres. 1869-70. 

HiCKiNBOTHAM, James, M.Tf., Ptiysicisn to tlie Birming- 
ham and Midland Hospital for Women ; 2t), Broad 
street, Birmingham. 

Hicks, Edward John W,, M.D., CM., Port Elliot, South 
Aiistralia. 

(s, John Bbaxtob, M.D., F.R.C.P., F.R.S., Physician- 
Accoucheur to, and Lecturer on Midwifery and the 
Diseases of Women and Children at, Guy's Hospital ; 
24, George street, lUnover square. Cuundl, 1861-2, 
1809, lion. Stc. 1863-65. Viee-Pret. 1860-68. 
Twa*. 1370. Prf». 1871-2. 

HiGGB, Thomas Fbepekic, L.R.C.P. Ed., Beaconsfield 
House, Dudley, Worcestershire. 

Hill, James, M.D., I, Berlteley Gardens, Keasington. 

Hill, T. Wood, L.R.C.P, Ed., 96, Earl's court road. West 
Cromwell road, W. 

Hilliabd, RoBEUT Hasvey, M.D., Fairmead House, 5, Bel- 
grave lerrsce, Upper Holloway road, N. 

HiNTON, Jamk3 Thomas, Croydon, Surrey. 
1876 Hoar, William, Maidstone, Kent. 

O.F. Hodges, Richakd, M.D., F.R.C.S., 25, York place. Baker 
street, W. 

HoFFMEiSTEH, WiLLiAM Cabteb, M.D., Surgcon to the 
Queen in the Isle of Wight ; Cliftou House, Cowea, 
Isle of Wight. Council, 1877-9. 

HoLLiNGS, Edwin, L.R.C.P. Ed., 4, Gordon street, Gordon 
square, W.C. 

HoLMAN, Constantine, M.D., Barons, Reigate, Surrey. 
Covmil, 1867-69. Fice-Pret. 18rO-7l. 



1867 



1870 



1800 Hic 



1860 



1880 
1879 



, 1872 



J878 



, 1664 



1875 



I 1859 



XXXII FELLOWS OP THS 80C1BTT. M 

Elected 1 

1880 HoNiBALL, OacAB. DcNscoHBE, M.D., Nev Amsterdam, 

Britiiih Qui ana. 
I86J Hood. Whaktox Peter, M.D., 65, Upper Berkeley street, 
Portman square, W. 

1881 HopcKOFT. Thom*3, L.B.C.P. Ed., High street, Dorking. 
1872 Hope, William, M.D., Physician to Queen Charlotte's 

Lying-in Hospital ; 56, Curzon street, Mayfair, W. 
Council, 1877-9. 
1874 Hopkins, Alfhed Born, 180, Shoreditch, E. 

1876 Huksman, Godfuey Charles, 22, King street, Portman 

square, W. 
1864 Houghton, Henry G&obqg, L.K.Q.C.P. Ireland ; 6, Moant 
street, Grosvenor square, W. 

1877 Howell, Hobace Sydney, M.D, 11, Boundary road, 

St. John's Wood, N.W. 

^M 1879 Howie, James Muik, M.D. Edin., 50, Rodney street, 
^H Liverpool, 

^H 1679 HtBBARD, Tbohas Wells, 6, Gordon street, Gordon 
^M square, W.C. 

^H 1878 Husband, Walter Edward, 56, Bury New Road, Man- 
^H cheater. 

^1 1859 Hutchinson, Jonathak, F.R.CS., Surgeon to the London 
^1 Hospital; 15, Cavendish square, W. Counct^ 1869-71. 

^^ Fice-Pru. 1881-2, 

^H 1861 HUTTOK, Charles, U.J)., Physician to the General Lying-in 
^^M Hospital ; 26, Lowndes street, Belgrsve square, S.W. 

^H 1877 Ilott, James John, L.R.C.P. Ed., Resident Medical Officer, 
^H Whitechapcl Union Infirmary, Baker's row, E. 

^H 1879 Inkson, James, M.D., Sargeon -Major, Army Medical De- 
^H partment; care of Mr. J. Tajlor, 37, Albert square, 

■ Claphan.. 

^H 1876 luwjN, John Arthur, M.D., M.A., 235, Brunswick street, 
^^M Manchester. 

^H ]SG4 Jackson, Edward, M.B., Surgeon to the SlieOield Hospital 
^H for Women ; Fern Bank, Gloseop road, Sheffield. Hon. 

^H Loe. Sec. 

^1 1864 Jackson, Bobebt, M.D., 53, Netting hill square, W. 



■ FELLOWS Of Till;: sociUTV. xxxm 

f 1876 JiKlKs, -Isaac Neods, 32, Osnabnrgk street, Regent'a park, 

N.W. 
I 1873 Jakins, William Vospek, L.R.C.P. Ed., Start itreet, 

Ballarftt, Victoria. [Per hsac N. Jakins, Esq., 32, 

Oaiiaburgh street, Regent's park.] 
1872 Jalland, Robert, HonicaBlle, Lincolushire. 
I 1878 James, Walteb Culver, M.D., M.C, II, Marloea road, 
I Kensington, W. 

I 1877 Jamieson, Patrick, M.A., 3, St. Peter'a street, Peterhead, 
I Aberdeenshire. 

1 1881 Jeffcoat, James Henry, Surgeon Major, Army Medical 
I Department, Fort Pitt, CLatliam. lion. Loe. See. 

[ 1877 Jenks, Euward W., M.D., Professor of Medical and Sur- 
I gieal Dieeases of Women nnd of Clinical Gynecology, 

I Cbicngo Medicul College ; 1 70, Slate slreet, Chicago, 

I lllinoiR, U.S. 

I 1877 Johnson, Samdel, M.D., 5, Hill atreet, Sloke- upon -Trent. 
I 1881 JoBNSTOK, JoaEPii, M.D., Brigade Surgeon, Army Medical 
I Department ; St. Jolin'a Wood Barracks, N.W. 

I 1879 Johnston, Wm. Beech, M.U., 157, Jamaica road, Ber- 
[ mondeey, S.E. 

I 1868 Jones, Evan, Ty-Mawr, Aberdarc, Glamorganshire. lion. 
I Loc. See. 

1 J878 Jones, H. Macnaughton, M.D., Physician to the Cork 
I Maternity, nad County and City of Cork Hoapital for 

Diseases of Women and Children ; St. Patrick's place, 

Cork, 
1881 Jones, James Robert, M.B., Hospital for Women, Soho 

square. 
1868 Jones, John, 60, King street. Regent street, W. 
1874 Jones, John Thomas, L.K.Q.C.P. I., 179, Brixton road, 

S.W. 

L 1676 Jones, Leslie, M.D., CM,, 3, Brighton parade, Blackpool. 
JJ873 Jokes, Philii- W,, Silver street, Enfield, Eisei, 
^1873 Jones, Thomas Debrv, L.R.C.P. Ed., 328, Upper street, 
Islington, N. 

VOL, XXIIl. C 



XXXIV FELLOWS OF TUE SOCIETV. 

Elected 

18G8 Jordan, William Ross, Surgeon to the Birminghmn Hos- 
pital for Women ; Manor House, MoBcley, near Bir- 

1870 JoDHERT, CuABLEs Henry, M.D., General Hospital, Cal- 
cutta; care of Meaars. Gray and Co., 21, Canning 
street, Calcutta. 

1878 Jddson, Thomas Robert, L.R.C.P. Lond., Hayman's 
Green, West Derby, Liverpool. 

1875 Jukes, Augcstds, M.B., St. Catherine's, Ontario. 

1878 Kane, Nathaniel H. K., M.D., Lanherne, Kingston hill, 

Surrey. 
1880 Kebbell, Alfbed, Flaxtou, York. 
O.F. Keele, Geohge Thomas, 81, St. Paul's road, High- 

bory, N. 
1874 Kempstek, William Henry, L.R.C.P. Ed., Onk House, 

Bridge road, Battersea. 

1879 Keb, Hugh Riciiari>. L.R.C.P. Ed., Comberton House, 

HalcB-Dwen, Birmingham. 
1855* Kernot, Geoboe Charles, M.D., .5, Elphinetone road, 

Hastings, Sussex. 
1872 KBRtt, NoRMAK S., M.D., F.L.S., 42, Grove road, Regent'B 

park, N.W. 
1877 Kerswili., Geoboe, Looe, Liakeard, CornwalL 

1877 Kerswill, Jonu Bedford, M.R.C.P. Ed., Fairfield, 8t, 

German's, Corownll. 

1878 KuoRY, RusTONJEE Nasekwanjee, M.D. Brussels, L.Med, 

Bombay, Physician to the Parell Dispensary, Bombay, 
Lecturer to Native Midwives, Grant Medical College, 
Bombay. [39, St. James's square, Holland park.] 

O.F. EiALLMARK, Henry Walter, 5, Pembridge gardens, Bayi 
water. Council, 18/9-80. 

I860- Kingsford, Edward, F.R.C.S., Surgeon to the Sunbury 
Dispensary ; Sunbury, Essex. 

1862 KiRKPATBicK, John Rctherfohd, M.B. Dubl., EiamineriD 
Midwifery, Royal College of Surgeons, Ireland ; 4, 
Upper Merrion street, Dublin. Coaneil, 1872-4. 



M.R.C.P. Ed., Liz Vilie, Elm groTe, 



FELLOWS OF THE SOCIETY, XSXV 

EUeled 

1872* KiscH, Albert, 3, Sutlierknd gardens, Maida vale, W. 

1867 Knaqos, Henri Ou4rd, M.D., 189, Camden road, N.W. 

1877 Kniqut, Cuakles Fi^euebick, 34, Claremont square, 

N. 
1876 Knott, Chari 

Soutbsea. 
1881 Lacy, Ciiahles Setuwaud de Lacy, M.B., 5, Ovington 

square, S.W. 
1876 Lancuesteh, Hehky Tuouas, M.D., Park House, Park 

lane, Croydon, Surrey. 

1878 Lanb, Alex. M,, M.B., 41, Warwick road. South Kensing- 

ton. 
1867 Lanafobd, Charles P., 29, Duncan terrace, Islington, N. 
O.F. Lanqhore, John Chauleb, M.D., F.R.C.S., 2U, Oxford 

terrace, Hyde park, W. CouHcil, 1861-6-4. Viet' 

Pre$. 1869-71. 
1872 Lattey, Jaue:i, 23, St, Mary Abbott'i terrace, Keoaington, 



1875 Lawhekce, Alpbeo Edwabd Aubi, M.D., Phyaician- 

Accoucheur to the Bristol Oeueral Hospital ; 15, 
Richmond bill, Clifton, Bristol. 
1878 Leachmas, Alhebt Wabren, M.D.,, Fairley, Petersfield, 

1876 Leiohton, Walteb Henhy, M.D., Lowell, MaaaachusetlB, 

U.S. 

1860 Leibhman, William, M.D., Physician to the Unii-ersily 
Lying-in Hospital, Uegius Professor of Midnifery in 
the University of Glasgow i 11, Woodtide crescent, 
Glasgow. Council, 1866-68. Viee-Pre». 1869-70. 

1881 Le Page, John Fisueb, L.R.C.P, Ed., Meadowfield House, 
near Durham. 
[ 1874 Lewis, Chakles Francis, L.H.C.P. Ed., Bromeeld'a, 
Henfietd, Sussex. 

[ 1877 Lewis, John Rioos Millkb, M.D., Deputy- Surgeon Genera], 
Woodlanda, Queen's road, Norbiton, S.W. 



XXSVl FELLOWS OF THE SOCIETY. 

Elected 

1875 LiEBMAN, Carlo, M,D. Vienna, Principal Surgeon, TrieBte 

Civil HoapiUl, Trieste, Austria, 

1876 LiLLEV, Geobge Uebbebt, M.D., M.R.C.P., Assistant Sur- 

geon H.M.'s Convict Prison, Portland, Dorset. 
1673 Lindsay, W. B., M.D., Strsthroj, OnUrio, Canada. 
1874 LiTHOow, Robert Alexander Douglas, M.B.C.P. Ed., 

M, Cadogan place, S.W. 
1890 LiTHGow, Thomas G., Paniboro', Hampshire. 
1868 Llewellyn, Evan, L.R.CP. Ed., 9, Mount place, London 

HospiUl, E. 
1872* Lock, John Griffith, M,A., Lansdowne House, Tenby. 
1859 LoMBE. TuoMAs Robert, M.D., Bemerton, Torquay. 
1870 LoNO, Mabk, M.D., Ludlow, Salop. 
1873 LoBiMEE, John Archibald, 33, Castle street, Farnliam. 
1876 LovETT, Henby Albert. Tasmania. 
1862 Lows, George, F.R.C.S., 5, Uarniuglow street, 6urton-on- 

Trent, Staffordshire. 
186C Ldcey. William CuBiTT, M.D., Tlie Elms, Buslhill Park, 



V, F.R.C.P.Ed., Associate of 
Fyfield House, Andover. 
Hollies," Graiseley, Wolver- 



Enfleld. 

1873 Lush, William John He; 
King's College, Loiidoi 

1878* Lycett, John Allan, The 
bampton. 

1869 Lydall, Wykeham H., L.E.C.F. Ed., 19, Mecitlenburgh 
square, W.C. 

1871 McC.ALLCM, Duncan Campbell, M.D., Professor of Mid- 
wifery and Diseases of Women and Children, McGill 
University ; Physician to the University Lying-in 
Hospital; and Physician to the Montreal General 
Hospital i 45, Union avenue, Montreal. Canada. 

1878 Macdonald, Albert Angus, M.B., 109, Queen street 

West, Toronto, Canada. 

1879 MacGbath, William Michael, L.K.Q C.P.I., 32, Colville 

terrace, Bayawater, W. 
1879 Mackeocob, Geobqe J., M.D., Chatham, Ontario, Canada. 



FELLOWS OF THE SOCIEXr. XXSVll 

[ Eleet§d 

O.F. MACKts'DEit, Drapek, M.D., ConBulting-Siirgeon to the 
Gniaaborough DiEpensacy; Gaineboroiigb, LincoInBhire, 
Oomcil, lt*7l-3. 

1879 Machcrin, Henby Nokuand, M.D., 155, Macquarie 
street, Sydney, New South Wales, 

1879 Macneilage, Da-vjd, L.R.C.P, Ed., 5, Hilda place, Salt- 
burn, Yorksbire. Hon, Loe. See. 



MacSwinney, Gkokge 

Brook green, Ilaiuinersniitb. 
Madoe, Henby M,, M.D., '1, Uppi 



1673 



M.D., WestaU Houae, 



Council, 18C3-65. 
Malins, Edward, M.D. 



Wimpole street, W. 
Fice-Fret. I872.i. 



Obstetric Phyaician to the 
ngham ; 8, Old aquare, Bir* 



King street, Wolver- 
Farn- 



Geueral Hoapital, Bin 

mingham. Council, 1881- 
Manbt, Frederick Edward, 

hampioD. 
Manders, Horace, 1, York terrace, York town, 

borotigh Station. 
March, Henry Colley, M.U., 2, West street, Roch- 
dale. 
Marley, Henry Frederick, Padatow, Cornwall. 
Marriott, Bobekt Buchanan, Swaffbam, Norfolk. 
Massb, Thomas Charles, 56, Fitzrov street, Fitzroy 

square, W. 
Marshall, Francis John, Reatdent Medical Officer to St. 

George' a Hospital. 
Mabtin, Henry Charrington, M.B., CM., II, Somera 

place, Hyde park, W. 
Mason, John Watlis, 1, Oanaburgh terrace, Regent'a 

park, W. 
Mason, Sauuel Butleu, L.B.C.P. Ed., Denham Houae, 

11, Park terrace, Pontypool, Montnouthsbire. 
Macnsell, H. Widenhah, A.M.. M.D., Pitt and London 

street, Dunedin Ncv Zealand. 



XXSVIll FELLOWS OP THE SOCIKTV. 

Elected 

1877 May, Lewis James, Bountis Thome, Seven Sisters rofid, 

Fiiisbury Park, N. 
O.F. Meadows, Alfred, M.D., Physician -Accoucheur to, and 

Lecturer on Midwifery at, St. Mary's Hospital; 

27, George street, Hanover square, W. Council, 1862-6-1. 

//on.Sw. I8GJ5-66. Hon. itfi. 1865. TreM. 1867-69. 

Fice-Pres. 1874-6. 

1875 *MiLES, AuiJAH J., M.D., Professor of Diseasea of Women 

and Children in the Ginciunati College of Medicine, 
Cincinnati, Ohio, U.S. 
1871 Miller, Hugh, M.U., Fbysician-AccoucbeurtotbeGlaagov 
Maternity Hospital ; 298, Bath crescent, Bath street, 
Glasgow. 

1876 MiLLMAN, TnoMAB, M.D., Asylum for the Inaane, London, 

Ontario, Canada. 



181 



1867 
1873 



1877 
1873 



1879 
1869 



Mills, Robert James, M.B., M.C., All Sniots' Green, 
NorwieU. 

MiLsoN, BicHARD Henrt, M.D., 88, Finchley road. South 
Hampstead, N.W. 

MiLWAED, James, 27, Charles Street, Cardiff. 

Minns, Pembroke R. J. B., M.D., Thetford, Norfolk. 

Mitchell, Robert Nathal, M.D., Chester House, Wick- 
ham roni], LeirishHra High road, S.E. 

MoNCKTON, Marshall, L.F.P.S. Glasg., 20, Melville road, 
Maidstone. 

MooTHoosAWMY MooDELLY, P. H., M.D., F.L.8., Native 
Surgeon, Uncovenanled Service, and Teacher of Mid- 
wifery, L. F. Midwifery, Manargoodi, Tanjore District, 
Madras Presidency. 

Moon, Fbeoekick, M.B., Bexley house, Greenwich. 

Moon, Robkbt Henkt, F.B.C.S., Fern Lodge, Lower 
Norwood. 

MooRB, Geobgb Edward, M.B., Maidenhead. 

MooRK, Joseph, M.D., Uaroldean, Thornton Heath, 
Surrey. 

MoOBHEAD, JontJ, M.D., Surgeon to the Weymouth Iiifir- 
mary and Dispensary ; Weymouth, Dorset. 



1879 



1877 
O.F. 

18B0 

1863 

1859 



1876 

1881 



1876 
1859 



fCLLUWS or THE ! 



MovLLiv, James A. M&nsell, M-A., M,0., 17, George 
BUeet, Hid over square, W. 

Movtat. GeosQE, l.ooglaud House, Swansea. 

Mlib, James C. P.. L.B.C.P. Ed., 44, Cornwall roaa, WmU 
boume park. 

MCHPHT, James, M.D., Sui^on to the Hoapital for 
Women and Children, Sunderland, and Lecturer ou 
BoUny in the Uuivenity of Durham College of Medi- 
cine at Newcaatle-upou-TyDe ; Holly House, Sunder- 
land. Hon. Loe. See. 

Mlrkav, GtisTAVUs CuARLEs P., M.D., Obstetric rhysiciau 
to tUe Great Northern Hospital j 66, Great Cumber- 
land place, Hyde park, W. Couneil, 1864-65. Hon. 
Sec. 1866-69. Fiee-Prei. 1870-72. Treat. 1873-77. 

MuERAV, i. Jabdin'e, 99, Montpelier road, Brighton. 

MtJsGRAVE, JouNSOK Thomas, L.B..C.P. £J., Irlnm villa, 
39, Fiuehley road, N.W. Couneit, 1859-60, 

Nall, Samuel, Casualty Pliysician, St, Bartholomew's 
HoBpital, E.C. 

Nason, John James, M.B. Load., II, Bridge street, Strat- 
ford-on-Avon. 

Neal, Jahe3, M.D., late Hon. Surgeon to the Lying-in 
Hospital, Birmingham ; Barcelona Hoiuc, Sandown, 
Isle of Wight. 

Keilc, James Edward, M.D., Lecturer on Forensic Medi. 
cine, Melbourne University; 166, Collins street east, 
Melbourne. 

Nesbitt, Dawson, M.D., 34, Cambridge place, Hyde Park,W. 

Netuebcupt, William IIksry, Resident Medical Super- 
inlendeni, Chelsea Infirmary, Cale street, S.W. 

Newhah, Jame!(, 16, Princes slreel. Cavendish square, W. 

Newkan, William, M.D., Surgeon to the Stamford and 
Rutland Infirmary; Barn Hill House, Stamford, 
Lincolnshire. Council. \%7'A-7fi. Viee-Prea. 1876-77. 

Nicholson, Akthcr, M.B. Lond., 98, Montpellier road, 
Brighton. 



FELLOWS OF TEE SOCIETY. 



Elected 

1879 NiCHOLSo: 



!3 RowLEir, M:.D., 89,Caniden road, N.W. 
1876 Nix, Edward James, M.B., l-);i. Great Portland street, W. 
1876 Oases, Cdaeles, M.B. and CM., Tlie Parade, Leamington. 
18S0 Oaklet, John, HoUy HottBe, Wood's End, Halifai, York- 

1868 Oates, Pakkinson, M.D., 164, Cambridge atreet, Eccleston 

aquare, S.W, 

1876 Ogston, Fbancis, Junr., M.D., 1 6, Bridge Btreet, Aberdeen. 
O.F. Oldham, Henhy, M.D., F.R.C.P., Consulting ObBtetric 

Phyaiciati to Goy'« Hoepital ; 4, Cavendish place, Caven- 
disli Hquare, W, Fice-Fre». 1859. Council, I860, 
1865-66. Treas. 1801-62. Prei. 1863-64. Triutee. 
1878 O'Neill, Joiik, M,D., Maldun, Victoria, Australia. 

1869 Obu, George Rice, Streatham hill, Surrey, ConneU 1881. 
1880 Orton, Charles, M.R.C.P. Ed., Nelson place, Newcastle- 

nnder-Lyme, Staffordshire. 

1877 OsTBBLOH, Paul Rudolph, M.D.Leipzic; Dresden. 

1877 Obtlebb, Robert, M.B., CM., 28, Stoke Nevington 
road, N. 

1863 Oswald, James Waddell Jeffbies, M.D., 24.'>, Ken 
ningtou road, S.E. 

1880 Odthwaitk, William, Herbert House, Denmark Hill, S.E. 

187.5 Owen, William, 28, Share road. Hackney, E. 

1877 Palmer, Montagu H. C, London road, Newbury, Berka. 

1877 Fabamobe, Richard, IS, Hunter street, Brunswick square, 
W.C. 

1873 Pabkeb, Robebt William, 8, Old Cavendish street, W. 

1867 Parks, John, The Wylde, Bury, Lancaabire, 

1873 Parks. Ldtiieu, A.M., M.D., 1. Place Duplaa, Pan, Prance. 
[Agents; Messrs. Baring Brothers & Co., 8, Bishox>Bgate 
street within, E.G.] 

1872 Pars, Geohqe, M.D., 18, Upper Pbillimore place, Kensing- 
ton, W. 

1880 Parsons, Sidnev, 78, Kensington park road, W. 



FBLLOWB OF THE 90CIETV. 



\\i 



EUeted 

1865* Pateeson, Jaues, M.D., Hayburn Bank, Pnrtick, Glasgow. 
1879 Pauli, Theopbilus William, L.R.C.P. Ed., Luton, Beds. 
1874 Payse, William 8. Hele, 87, Queen's Road, Peckliam, 



1864 
1871 



1873 
1881 
1871 

1879* 
1879 



1871 
1876 



1876 
1866 



Peaeson, David Ritchie, M.D., 23, Upper Pliillimore 

place, KenaiDgton, W. 
Pedleb, George Henby, 6, Trevor terrace, Rutland gate, 

S.W. 
Fedlst, Tuouas Franklin, KaDgoon, India. 
Pe£L, Kobeut, 120, CoUina street eaat, Melbourae, Victoria. 
Peikce, Bicmabi) Kino, Surgeon to tlie Notticg kill and 

Shepherd's Bush Dispensary, 96, Addison road, 

Kensington, W. Council, 1881. 
Penny, Geokge Town, B.A., Swnley Hou«e, Rotherfield 

street, Islington, N. 
Febez, Diego, M.D., Montevideo, South America. 
PfiaiGAL, AiiTHtR, M.D., New Baniet, Herts. 
Pebbigo, Jahes, M.D., 163, Blenry street, Montreal, 

Canada. Hon, Loc. See. 
Pesikaka, HoRMASJi DosABHAi, 23, Hornby row, Bombay. 
Phibbs, Robert Featherstose. L.R.C.P. Ed., Pelliam 

House, 30, Sutherland gardeiiH, Maida vale, W. 
Phillips, George Kicbabu Tubneb, 24, Leinster square. 

Bays water, W. 
FiiiLroT, Joseph Henry, M.D., 26, South Eaton place, S.W. 
PHILP3, Philip Qeobge, 4. Queen's road, Peckliam, S.E, 
PiCABD, P. KiRKPATBicK, M.D., 59, Abbey road, St. Jolin'a 

Wood, N.W. 
Pi GO, TuoMAs, M.D., Pliysician to the Manchester 

Southern Hospital for Women and Children ; 98, 

Mosley street, Manch eater. 
PiOGOT, Allen, L.R.C.P. &<]., Boarneville Lodge, Becken- 

ham, Kent. 
PiLCHBB, William John, 43, High street, Boston, Lincoln- 



xlii FELLOWS OP THE SOCIETV. 

Elected 

1864 Playfaib, W. S., M.D., F.R.C.P., Physician Accoucbenc 
to H.I. & R.H. the Ducheas of Edinburgh; Pro- 
fesBor of Obstetric 31edicine in King's College, and 
ObBletric Phyeieian to King's College Hoepitali 31, 
George street, Hanover Square, W. Council, 186?, 
Son. Librarian, l8fi8-9. Hon. See. 1870-72. Fice- 
Pres., 1873.5. Prei. 1879-8li. 



1880 



:. Mark's 



PococK, Frederick Ernest, M.D,, The Limes, ' 

road, Notting hill, W. 
O.F.' PoLLAED, William, Surgeon to the Torbay Hoapital j 

Southlands, Torquay, Devon. 
1877 Poole, 8. Wordsworth, M.D., Dunedia, Sidcup, Kent. 
1876 Pope, H. Campbell, M.B. Lond., BroomBgrovo Villa, 280, 

Gold Hawkroad, Shepherd's Bush, W. 
1864 PoTTEB, John Eapti3TE, M.D., Obstetric Physician to, 

and Lecturer on Midwifery and the Disenses of Women 

8t, the Westminster Hoapital ; 20, George street, 

Hanover square, W. Council, mT-2-6. Hon. Lib. \B77-8. 

Vice.Pret. 18/9-81. Treas. 1882. 

1875 PowDBELL, John, 160, Euaton road, N.W. 

1863 Powell, Josiah T., M.D., 347, Oily road, E.C. 

1864 Prioe, William Nicholson, Lectnrer on Midwifery and the 

Diseases of Women and Children at the Leeda School 
of Medicine ; Mount Pienaant, Leeda. Council, 1876-8. 

1880 Prickett, Mahhaduke, M.D., 43, Albion street, Hyde 
park. 

O.F. Priestlbv, William 0., M.D., F.R.C.P., Conaulting 
Obstetric Physician to King's College Hospital ; and 
Consulting Physician-Accoucheur to the St. Marylebone 
Infirmary; 17, Hertford street, Mayfair, W. Council, 
1859-61,1865-66. Fice-PrM. 1867-69. PrM. 1875-76. 

1876 QuiBKE, JosRPH, L.R.C.P. Ed,, The Oaklands, Hunter's 

lane, Ilandsworth, Birmingham, 
1879 Raitt, Thomas, M.D., Hill house, Woolwich, Kent, S.E. 



JELLOWS OF THB BOCILTV. xllll 

Elecled 

O.F. Randall, John, M.D., Lecturer on Mcdicnl Jurisprudence, 
St. Mary's IIoBpitnl Medical Scliool ; Medical Officer, 
St. Maryleboue Infirmary; 35, Nottingliam place, W. 
Council, 187". 

1861 Rasch, ADOLPars A. F., M.D., Pliyaiciaa for DiseftBea of 

Women to the German Hospital; PhyaicUn to the 
Training Hospital, Toitenham ; 7, South street. Fins- 
bury square, E.C. Council, 1871-3. 

1878 Eawlings, Johk Adams, M.R.C.P. Ed., 4, Northampton 

terrace, Swansea. 
1870 Ray, Edwaed Reynolds, Dulwich, Kent, 8.E. 
1860* Kayner, John, M.D., Swnledale Houie, Quadrant road 

north, Highbury New Park, N. 
1859 Batnes, Henby, Gringley-on-lhe-Lill, Bavlry, Yorkshire. 

1879 Rkad, Thomas Laubbnce, II, Peterstiam terrace. Queen's 

gate, S.W. 

1874 REEa, William, Priory HouM, 129, Queen's crescent. Haver- 
stock hiU, N.W. 

1879 Reeve, Henby, 286, Mile Eud road, and 24, White Horse 
Jane, B. 

1879 Eeui, William Louuon, M.D., 7, Royal creeceut, Qlasgow. 

1879 Rekdle, Richard, 1 13, Queen street, Queensland, AuBlrnlia. 
1875" Eev, Euqenio, M.D., 39, Via Cavour, Turin. 

1862 RiciiABDS, David, 23, St. George's terrace, Kemp Town, 

Urighton, Sussex. 

1880 RicHABDs, Geobck, L.R.C.P. Ed., Mervjn Lodge, Ashetlds, 

KoBB, Herefordshire. 
1862 RiCHABDS, S. Smith C, 36, Bedford square, W.C. 
O.F. BiciiAUDsoN, RiCMABU, L.R.C.P. Ed., Bryugwy, Rhayader, 

Radnorshire. 
1872 Richardson, William L., M.D., A.M., Instructor in 

Obstetrics iu Harvard University; Visiting Physician 

to the Boston Lying-in Hospital; 70, Boylston street, 

BoBtoD, MassRchusettB, U.S. 
1872 RiODEN, Qeoroe, Surgeon to the Canterbury Dispensary; 

60, Burgate street, Canterbury. . 



xliv 



PELLOWa OF THE 



Sleeted 

1871 RiODBN, Walter, 231, Brompton road, S.W. Council, 1882, 

O.F.* Roberts, David Lloyd, M.D,, Phjsicinn to St. Mary's Hoa- 

pital, Manchester; 23, St, JoUd's street, Deansgate, 

Mancheiter. Council, 1868.70, 1880-2. Vice-Prei. 

1871-2. Ron. Loe. See. 

KoBERTa, David W., M.D., 56, MancbeBter itreet, Mau- 

cliefiter square, W. 
Robertson, William Borwick, M.D., West Dulwicb, S.E. 
Robinson, Thomas, M.D., 5, Woburn Bqiiare, W.C. 
1876 Roe, John Withington, M.D., EUeamere, Salop. 
O.F. Rogers, William Eicbakd, M.D., PbyBieian to the Sums. 
riian Free Hospital for Women anil Cbildren ; Con- 
BultiDg Physician to tlie Hospital for Women, Vincent 
square, S.W. ; 56, Jlernera street, Oiford street, W, 
Council, 1870-72. 

\, KingBtOD-on- 



18G7 



xaii 
O.F. 



1874 



1860 



i8;4 

18G5 



Roots, William Henbt, Canonbury Hoi 

Thames. 
RopEK, Alfred Geokoe, 57, North End, Croydon, Surrey. 

Council, 1879. Hon. Loe. See. 
RoPEB, Abthur, 17, Granville park, Blacklieatb. 
RoPEK, George, M.D., Physician to t!ie Royal Maternity 

Charity ; Physician to the Roynl Hospital for Diseasea 

of Children and Women, Waterloo Bridge road; 19, 

Ovington gardens, S.W. Chuneil, 1875-77. Fiee- 

Prci. 1879-81. 
Rose, Henrt Coopeb, M.D., High street, Hnmpatead, 

N.W. Council, 18/5-77. 
Ross, Datid Palmer, M.D., Eingstou, Jiimaica. 
Ross, Frederick Ogilbv, B.A., M.B., 8, The Terrace, 

High street, Kensington. W. 
RoUTii, Charles Henbt Felix, M.D., Pliysician to the 

SamariLin Free Hospital for Women and Cljildren ; 52, 

Montagu square, W. Council, 1839-61. Fiee-Prei. 

1.874-6. 



FELLOWS OF TflE SOCIETY, 



Eltfled 

18/4 Row 



Thomas, L.B.C.P. Ed., Hon. Physician to ibe 
Lying-in Hospital, Melbourne, Victoria. 
1881 RowoRTB, Alfred Thouas, Gray'a, Egsex. 
1870 EussELL, Logan D. H„ M.D., 8, AlfreJ street, Gt. George 
street, LiTerpool. 

18t>6 Sabuia, v., M.D., Rio de Janeiro, Soulh Americn. 

1864 Salter, John H., D'Arey House, Tolleahunt D'Arc;, Eel- 
Tedon, Essex. 

1875 Salzuann, Fredebick Wllliam ; Senior Surgeon to the 
Hospital for Women ; 18, MontpelUer road, Brighton. 
Couneil, 1860-2. Uon. Loe. See. 

1868" Sams, John Sdtton, St. Peter'a Lodge, Ellbam road, Lee, 
Kent. 

1872 Sanqster, Charles, 146, Lambeth road, S.E. 

1870 Saul, Willeam, M.D,, 4, Cbarlotte street, Fitiroy sqiinre, 
W. 

1SG3 Savaok, Hehry, M.D., Consnliing Pliysiciau to the Sam»- 
ritan Hospiial for Women, Lower Seymour street, 
Portman square; 14, Bentiuck street, W. Couneil, 
1871-2. 

1872 Savage, Tuomas, M.D., Surgeon to ibe Birminglism and 
Midland IlospiUl for Women ; 12, Old square, Bir- 
mingham. Council, 1878-80. 

1877 Savobt, Charles Tozee, M.D., 1, Douglas road. Canon- 
bury, N. 

1879 ScHOi-iELD, Rt. H. a., M.A., M.B. Oion. [eare of Mr. 
Dalziel, Inland Mission, Shanghai, China] 

O.F. Scott, John, F.E.C.S., 10, Tavistock square, W.C. Council, 
1868-70. Fice.prei. IB7i-3. 

1870 Scott, John, M.D., New street, Sandwich. 

187S ScoviL, FHANCia 3., II, Norton road. Hove, Siiimei. 

1863 Sequeira, Henry Littlb, 34, Jewry street, Aldgate, E.C, 
and Waltham Lodge, Tolse bill. 

1866 Seqckira, Jauf.s Scott, 6S, Leman street, Goodman's 
fields, E., and Crescent House, Casslaud Crescent, 
Cassland road. South Hackney. 



S OF THE SOCIETY, 

Eleeled 

1875 Skton, Datid Elphinstonb, M.D., 12, Tliurloe plsce, 
South Kensington. 

1860 Sewell, Chablbs Beodie, M.D., 21, Cavendish sqaare, 
W., and 13, Fenchurch street, E.G. Council, 1880-2. 

t8fi2 SsAaMAN, Malim, Surgeon to the BirmingliBm Free Hob. 
pital for Sick Children; 18, New HrII itreet, and 
KoUington, Bristol road, Birminglmni. 

O.F. Shaupin, Hknut Wilson, F.R.C.S., Surgeon to the Bed- 
ford General Infirmary, Bedford. Council, 1871-3. 

18G9 Shaw, Henby Sissmouk, 88, Upgaie, Louth, Lincoln- 
■hire. 

1875 Sheldon, Edwin Mason, Surgeon to Stanley UoapiUl; 

223, Boundary street, Liverpool. 
18(J7 Shepherd, Fuederick, L.E.C.P. £d., 33, King Henry's 

road. Primrose hill, N.W. 
1859 Shipton, William Pakker, Consulting Surgeon to the 

DevonaLire lloepitaJ ; Buiton, Derbyshire. 
1874 Sinclair, Alexandeh Doull, M.D., Visiting Physician to 

the Boston Lying-in Hospital ; Member of the Board 

of Consulting Phyaiciana and Surgeons, Boston City 

Hospital; 35, Newbury street, Boston, Massachusetts, 

U.S. 
1676 SiBiQNANO, GiustE, M.D., 2A, Strada Baachi Nuovi, Napoli. 
1874 Skinnbh, Stephen, M.B., Freudale, Clevedon, Sotuer- 

aet. 
1879 Slight, Gbobqe. MI)., 25, Brewer street. Regent street. 
1881 Sloan, Archibald, M.B., 5(3, Buccleugh street, Glasgow. 

1876 Sloan, Sampel, M.D., CM,, 4, Newton terrace, Glasgow. 
1861 Slyu AN, William Daniel, 2G, Cavcraham road, Kentish 

Town, N.W. Countil, 1881. 
1859 Smiles, William, M.I)., Surgeon to the House of Correc- 
tion, Cold Bath Fields; 44, Bedford square, W.C. 
Council, 1879. 

1877 Smith, Arthur Laptuiten, M.D., 41, Beaver Hall terrace, 

Montreal, Cniinda. 



FELLOWS OF THE SOCIETY. 



Smith, Heywood, M.D., Physician to the Hoepital for 

WomcD, Soho square, and Fliyaieian to tLe British 

Lying-in Hospital; 18, Harley street, Cavendish 

square, W. Council, 1872-5. 
Shite, Pbothehob, M.D.^ Physician to the Hospital for 

Women, Soho square ; 42, Park street, GroHVenor 

square, W, 
Smith, Kichabd Thomas, M.D., Aasiataut- Physician to the 

Hospital for Women, Soho square ; 63, Haverstock bill, 

N.W. 
SuiTU, Wh. Hugh Montgoueby, L.R.C.P.£d.| 24, London 

road. West Croydon, Surrey. 

Smith, Wilmam Johnson, M.D,, Consulting Physician to 
the Weymouth Infirmary and Dispensary ; Greenhill, 
Weymouth, Dorset. Council, 1869-71. 

SuiTU, Albert Ciiabi.es Butler, L.R.C.P. Ed., I, Hill- 
side, Crouch Hill, N. 

Snell, Edhdnd Oeobae CAHRtiTHEaa, !31, Green street, 
Tiotorift park, E. 
I Spaull, Barnard, F.R.C.S., Esses House, 29, Hammer- 
smith road. Hammersmith, W. 
I Spaull, Barnard E., Lynwood House, -17, Hammersmilh 



road, 

1876 Sp£NCEK, LlO] 

Messrs. Gr 



1676 
O.F. 



EL Dixon, M.D., Bengal Army [care of 
idlay and Co., 55, Parliament street]. 
Spry, G. Frederick Hlme. Surgeon-Major 2nd Life 

Guards, Army and Navy Club, S.W. 
SpvROtN, Herbert Bhanwhite, 49, Abington road, 

Northampton. 
Spderell, Flaxhan, L.R.C.P. Ed., BeWedere, Kent. 
SilDiRE, Wiluah, M.D.,M.R.C.P., 6, Orchard street. Port- 
man square, W. Council, 1866-68. Fiet-Prea. 1876- 



Staistdorpe, William Waters, M.D., CM., Wareham, 
Dorset. 



xlviii FEI.l.OWS OF THE SOCIETV. 

Elected 

1877 Stephenson, William, M.D., Professor of Midwifery, 

UiiiTersity of Aberdeeu ; 261, Uniou Street, Aberdeen. 

Council, 1881-2. 
1873 Stewart, James, M.D., 2, Skinner street, Wliiiby, Yorkshire. 
1875* Stewart, William. L.R.C.P. Ed., Highlield House, 

Barosley, Yorkshire. 
1876 Stewaet, William Edwabd, F.R.C.S. Ed., 16, Harley 

Street, W. 
1879 Stilwell, Robert R„ M.D„ Beckenhnm, Kent. 
1859 Stone, Joseph, M.D., X'A, Upper Brook street, Mnnchester. 
O.F. Stowebs, Nowell, 123, Kennington park rond, Kennington, 

S.E. 
1866 Strange, William Heath, M.D., 2. Belsize avenue, 

Belsize park, N,W. Council, 1882. 
1871 Stubges, Montague J., M.D.,Elmstone House, Beckeaham, 

Kent. 

1879 SuTCLiFFE, John, 108, Denmark hill, S.E. 

1880 ScTHEBLAND, Chables James, Ij.R.C.P. Ed., 16, Frederick 

street. South Shielda, Durham. 
1862 Sutton, Field Flowers, M.D., Balham hill, Clapham, 

S.W. 
1859 SwATNE, Joseph Gbifjithh, M.D., Physictan -Accoucheur 

to the Bristol General Hospital ; Karewood House, 

74, Pembroke road, Clifton, Bristol. Council, 1860-61, 

Vice.Pres. 1862-64. Hon. Loc. See. 

1879 Tait, Edwakd W., 54, Highbury park, N. 

1871 Tait, Lawson, F.R.C.S., Surgeon to the Birmingham and 
Midland Hospital for Women ; Consulting Surgeon 
lo the West Bromwicli Hospital ; 7, Great Charles 
street, Birmingham. 

1880 Takaki, Kanaueiro, F.R.C.S., Imperial Naval Hospital, 

Tokio, Japftu. lion. Loc. Sec 
1871 Tanner, John, M.D., F.L.S., Physician for Diseases of 
Women, to the Fnrringdon General Dispensary, and 
Obstetric Physician to tiie Lying-in Charity, Holborn ; 
102, Harley street, Cavendish square, W. 



PBLLOWB Of THE SOCIETY. XlXX 

EteeleJ 

,1859 TiPsos, ALrKED Joseph, M.S. Lond., 36, GImicesler gnr- 

dens, Weatbaume terrace, W. Couneil, 1862-64. 
a863 Tapson. Joseph Alflied, Surgeon to t!ie Clnpbsm General 

Uiapeusary ; H'S, lligh street, Clnpham, S.W. 
1871 Tayler, FbancisT., B.A. Lond., and M.B., ClareinontTilla, 
2^4, Lewisliftm high road, S.G. 
Tavloe, Edward, South lodge, Clapbam common, S.W. 

QjMncit, 1882. 
Tayloe, Charles, M.D., Pine house, Caraberwell greeu, 

S.E. Couneil, 1869-71. 
Tayloe, F. Perley, F.R.C.S. Ed., Charlotte Town, PriDce 
Edward Inland, Cauada. 
]8ti9 Taylor, John, Earl's Colne, ILdxlead, Eaeex. 

1871 Tatloe. John W.. M.D., Rothsay House, Priuce of Walea 
terrace, Scarborough. 

1862 Taylor, Thomas, F.B.C.8,, .'>, Wellington terrace, Sutton 
Coldfield, Birmingham, ChuncU, 187^-77- 

1872 Temple, James Algernon, M.U., Professor of ObBtetrica, 
Trinity College; Physician to Toronto Geueral Hospital; 
Pliyaician Accoucheur to the Burnside Lying-in- 
Hospiiai ; 191, Simeoe street, Toronto, //on. Loc. See. 

1662 Thane, Gkorge Dancer, M.D., 15, Montague street, 

Russell square. W.C. Council, 18M. 
18b0 Thompson, Henry, L.R.C.P. Lond., Ansistnrit Surgeon, 

Hull Geueml lutimiary, 16, Albion street, Hull. 
1870 TiioupsoN, JotJN AbiiBUUTON, M.D. (travelling). Couneil, 
1S77-8. 
167 TflOMPsoN, JosEPU, L.R.C.P. Lund., 24a, Regent street, 

Notungham. 
178 Thomson, David, M.D., 17, Market hill, Luton, Bedford- 

180 Thomson, John Anstbijtheb Mcltille, Bridge Houte, 

Newport, Shropshire, 
174 TnousoH, William Sinclair, M.D., 40, Ladbroke grove, 

Kensington park gardens, W. 
VOL. xxiii. d 



1 FELLOWS OF THE aOClETV. 

1878 Thomson, William Arnold, F.R.C.S.I., The LiniM, 

Ampthill, Beds. 
1867 Thorbdtin. John, M D., M.R.C.P., Professor of Obetetric 

Medicine, Owen's College, Manchester; 62, Gingstreei, 

Maucbeater. Council, 1876-78. Vice. Pres. 1881-2. 
ISfiO Thobne, Gdobge Lewdhthy, M.B., Lenham, near Maid- 

stone, Kent. 

1879 Thounton, J. Kfowslbv, M.B., CM,, Surgeon to the 

Samaritan Free Hospital for Women and Children, 22, 
Porlmaa street, Portman square. Council, 1682. 

1867 Thornton, Wiliiam Henry, Surgeon to the Royal National 
Hospital for Scrofula ; Berkeley Lodge, Margate. 

1874 TiCEiiUKST, Augustus Rowland, Silchester House, Peven- 
sey road, St. Leonard's-on-Sea. 

1873 TicEHUKST, Charles Sage, Peterafield, Hants. 

1860 TiFFEM, RoBEBT, M,D., Wigton, Cumberland. 

1866 TiLLET, Samuel, The Cedars, Craiiford, Middlesex. 

O.F. Tilt.Edward John, M.D., Consulting Physicisn-Accouchear 
to the Farringdon General Dispensary; 27, Seymour 
street, Portman square, W. Council, 1867-68. Vice- 
Prts. 1869-70. Treai. 18/1-2. Prei. 1873-4. 

1879 Tivv, William James, F.R.C.S. Ed., 1, Tottenham place, 
Clifton, Bristol. 

1872 ToLOTSOHiNOFF, N., M.D., Kieff, Russia ]_psr M. N. Orloff, 

13, Cambridge terrace, Walham green, S.W.]. 

1869 ToMKiNS, CuARLES p., L.K.Q.C.P.I., Beddington park, 

Croydon. 

1870 TowNB, Alexanueb, 364, Kingsland roaJ, N.E. 

1873 Trestrail, Henby Ernest, F.R.C.S.. M.R.C P. Ed., Walmer 

House, Victoria road, Aldershot. 
1872 Tuchhann, Maho, M.D., 148, Adelaide road, Haverstock 

hill, N.W. 
1865 Turner, John Sidney, Surgeon to the Aoerley Dispensary ; 

Stanton House, Auerley road. Upper Norwood, Surrey, 



■ THE BOriETV. 



I8S1 

1861 



1S73 



TUTHILL, Pun 



Tweed, John 
street, W. 
Underhill, Thomas, M.D. 

Stafibrd shire. 



EAB Barrett, M.D., Fort Pitt, Cbatham, 
James, Junr., F.R.C.S., 14, Upper Brook 



ramerfield, Weat Bromwich, 



, Metro 



Venn, Albert John, M.D., Obstetric Physii 

politnii Free Hospital; AsaietHiit Pliyiieinn, Viclorin 
Hospital for Sick Cliildren; 8, Upper Brook slreel, 
Gro»»enor square, W. 

Veiidon, Walter, F.R.C.S., 410, Brixton road, 8.W. 

Verlet, Reginald Louis, F.R.C.P. Ed,, 88, Gower street. 



1879 Wade, George Herbert, Ivy Lodge, Cliisleburet, Kent. 
1864 Wahltcch, Adolpbe, M.D., 8, Acorah street, Greenheys, 
MaDcbeater. 
Wales, Thomas Gabnkvs, Downhnm Market, Norfolk. 
Walker, George, L.R.C.P., M.R.C.S., 12, Lingfield road, 

mbledon. 
Walker, Thomas James, M.D., Surgeon to the General 
InfinnHry, Peterborough; 18, Weatgnte, Peterborough. 
Hon. Loe. See. Council, 1878-80. 
Walker, Thomas Osbokne, Crick, near Rugby, North- 

mptonshire. 
Wallace, Frederick, 9(3, Cazenove road, Upper Clapton, 

N. Council. 18S0'2. 
Wallace, John, M.D., Assistant- Physician to the Liverpool 
Lying-in Hospital; 1, Gambier terrace, Liverpool. 
Hon. Loe. Sec. 
' Walter, William, M.A., M.D., Surgeon to St. Mary's 
Hoepital, Rod the Manchester and Sall'urd Lying-iu 
Hospiul ; 20, St. John sircei, Manchester. 
Walters, James Hopkins, -13. Castle street, Reading, 
Berks. 
1873 Walters, John, M.B., Church street, Reignte, Surrey. 
O.F. Wane, Daniel, M.D,. 20. Graflon street. Bond *lrrct, W. 



1860 
1877 



I8G6 



1873 



1870 



1872 



FELLOWS OF THE 



1873 
1879 



1867 
O.F. 



Waruen, Ckakles, M.D., Hon. Surgeon lo the Uirming- 

ham L;ing-in HospilRl ; 39, Temple street, Itirming- 

liam. 
Watkins, Ciiablbs Stewaht, 16, Kiug WilliBm street, 

Strand, W.C. 
Way, John, M-D.,-!, Eatoo squBre, S.W. 
Wbathbrly, Lionel Ales., M.D., CM. Aberd., Portisheftd, 

Somersetshire. 
Webb, Fred. E., 1 13, Malda vale, W. 
Wkbb, Heney Spearman, Welwyn, Herts, 



1872 Web, 



L, Thomas, MaUern House, Reillniid, near Bristul. 



1876 
1S67 
1876 



1874 



O.F. 



1859 



1876 

1870 

I860 
1873 
1860 



Weir, Akchibald, M.D., St. Mungbo'a, Great Malvern. 

Wbllbr, Georob, The Mall, Wanstead, Esaex. 

Wblls, Fbank, M.D., late Professor of Obsletrics and the 

Diaenses of Women nod Children in the CleTelaud 

Medical School ; 12, West Cedar etreet, Boston, 

MassachiisettB. 
Wells, Hakry, M.D., H.B.M. Vice-Consul, Gualeguaycbu, 

Entre Rios, Argentine Confederation. 
Wells, T. Spe.ncer, F.R.C.S., Surgeon in Ordinary to 

H.M.'s Household ; Consniting Surgeon to the Samaritan 

Free Hospital for Women and Children ; 3, Upper 

Grosvenor street, W. Council, 1H59. Vice-Fret, 

1868-70. Truitee. 
Westmacott, John GtiBE, M.D., Medical Officer to the 

Paddington Provident Dispensary; Huwley House, 39, 

Howley place, Paddington, W. 
Wharton, Henhy Thohnton, M.A, Oxford, 39, St. George'a 

road, Kilbarn, N.W. 
Wheatcroft, Samuel Hansom, L.B.C.P. Ed., latchbBiD, 

Swnffham, Norfolk. 
Wheeler, Daniel, Chelmsford, Efisex. 
White, Frederick Broad, 15, Maida vale, W. 
Whitb. Fbedbrick Gboroe, L.R.C.P. Ed., 8, Dix's Field, 

Exeter. 
1877 Wiouore, WiLLiAU, 130, luTeruess terrace, Hyde park. 



lOfi? Wir.BE, Richard Hatrock, M.D., York Lodge, 21. Fiucliley 

road, St. Jubn'a Wood, N.W. 
1879 Wilkin, John FsEDEUtCK, M.D., Beckenbam, Kent. 

1876 Wilkinson, Joseph Cradock. 

1871 Wilkinson, William Henry Whiteway, L.R.C.P. Ed., 

268, CHledoniRD roBd, N. 
1879 WiLLANS, William Bldndell, F.R.C.P. Ed., Great Hnd- 

ham, HerU. 
1879 Willett, Charles Verr.u.l, Brnndoa, Suffolk. 
1861 Williams, Abtbdb Wvnn, M.D., Phyaiclnn to the Samari- 

Un Free llospitnli 1, Montagu Bquare, \V. Council 

1871. 
1864 Williams, Edward, M.D., Holt Btreet House, Wrexbsin. 
1867 Williams, Henry Llewellyn, M.D., 9, Leonard place 

Kenarngtun, W. 

1872 WiLi!iAM3, John, M.D.. F.R.C.P., Aasistant-Obatetric Pby. 
aiciau to UniTereity College Hospital ; 28, Harlej street, 
Cavendisb aquare, W. Cottnetl, 1875-76. Hon. Sec. 
1877-9. Fiee-Pre*. 1880-2. 

Willis, Julian, M.H.C.P. Ed., 82, Sutlierland gardens, 
Msida vale, W. 
I WiLLMOTT, JOLIUS JouN Eaudley, M.D., MelUourue, 
Australia. 

1873 Wilson, JoiiK Henry, L.K.Q.C. P. Ireland, Obstetric Pbysi- 
ciaD to the Ladies' Charity and Lying-in Hospital; 
Kensington Lodge, Kensington, Liverpool. 

I860 Wilson. Robert James, F.B.C.P. Ed.. 7, Warrior aquare, 
St. Leonvd's-on-Sea, Suuei. Bon. Loc. See. Fice- 
Pre*. 1878-80. 

1866 WiLTSumE, Alfred, M.D., F.R.C.P., Joint Lecturer on 
MidwiTer; at, and Assistant-Obetetric Physician to, 
St. Mary's Hospital, and Physician for the Diseases of 
Women to the West London Hospital; 57, Wirapole 
street. Cavendish squftre, W. Council, 1870. Hon. 
lAb. I87I-3. Hon. See. 1874.6. Viee-Prei. 1877-9. 

1877 Wintle, Ueski, M.B., 12, Park roaj villas, Forest bill, S.E. 



FELLOWS OF THE SOCIETV. 



Milecled 

1880 Woodward, G. 
road, TuliK 



P. M., M.D., Clarendon House, Norwood 
liUI. 
O.F. WoBSHiP, J. LccAS, Manor IIoUBe, Riverhead, Seveiioak*, 

Kent. Council, 1876-77. 
1881 WoRTHiNGTON, Geoege Finch Jen'ninos, Sidcup, Chiele- 

1876 WottTS, Edwin, 6, Trinity street, Colclieiter, 

1871 Yabbow, Gboegb Euoene, M.D., 87, Old slreel, E.C. 

Council. I8S1-2. 
1870 Ybatgs, Geoboe, M.D., Grove road, WalthamBtow, Essex. 
1874 Young, David, M.D., 13, Via dei Fobbi, Florence, Italy 

[care of Mr. Lewis, Gower Street]. 
1861 YoDNQ, William Butleb, 10, Castle street, Reading, Berks. 
1869 Yno, John S. C, Cnstlcfield House, 78, Walmuy road, 

Burv, LanraBhire, 



CONTENTS. 



Liat of Officers for 1882 . 

List of PresidenU 

List of Kflfereea of Papers for 1882 

Standing Committees 

Liat uf Honorary Local Secretaries 

TruBteea of the Societj'a Property . 

Liat of Honorary and Correaponding Pellowa 

List of Ordinary Fellciwa 

Contenta . . , , 

Liat of Plates .... 

AdverCie<;iuent .... 



January 12tli, 1881— 

Exfoliation of Teaieul Mocoqb Uerobrane. By Alban 

The Comparative Anatomy of the Lymphatics of the 
TJlema. By Geobqi: Hoooan. M B. 

Double Ovariotomy, exhibited by Dr. Matthkws 
DuNCAM fur Dr. Lkdiabd, of Carlisle 

A Syphon Donche, eziiibLted by Dr. Edib . 

Incomplete Rupture of Vagina, discovered post- 
mortem. Death from Septicxmia : TJlerua and 
neighbouring porta, ahown by Dr. Chahpnhts 
I. Complete Extirpation of the Uterua with both ovari 
weighing ten pounds ; recovery. By Thouas 
Chaubcbs. F.R.C.P. Ed. 
IL A case of Chronic Complete Inveraion of the Uterus, 
ancceasFully treated by saetained fllactic pressare. 
By W. E. RoQKRs, U.D. 



^^F Iri CONTENI'S 


^ 


^^H 


p„.i 


^^1 m. Delivery in a ease of Doable TTteraa. By J. Mat. 




^H THEW8 Duncan, M.D.,F.a.S.Edin. 


21 


^^B IT. Case i.f Pregnancy with Double Uterae and Vagina, 




^^H By J. Bkaxtoh Hicks, M.D-, F.a.S., &a. 


23 V 


^^H Y. Tertical Septum in lower part of Vagina impeding 


»| 


^^M labour. By J. Bbaxton Hicrs, M.D.. F.R.S., Sc. 


^^H VI. Supplement to a Papar on Fibroid Tumour compli- 




^H^ eating Delivery. By W, S. Playfair, M.D., 




^H F.R.C.P. ..... 


25 


^ft FebruaiT 2nd. 1881- 




^^H Annual Meeting .... 


31 


^^H Depression of the Frontal Bone in Two InftmtB, eibi- 




^^M bited by Dr. Godson .... 


32 


^^H Modification of Hodge's Pessary, shown by Dr.GEKVlB 


33 


^^H Extra- Uterine Pregnancy, A specimen shown by Dr. 




^^H BCRTON ..... 


34 


^^H VII. Case of Villous Degeneration of the Endometrium. 




^H By D. G. MacGallum. M.D. . 


37 


^^B The Audited Report of the Treasurer (Dr. H. 




^^1 Gebvis) .... 42~3 


^^^H Report of the Honorary Librariim for ISSO (Dr. 


^^ 


^^H G. EenebtHeruan) . 42— ^| 


^^^1 Report of the Boajd for the Examination of Midwives. 


^ 


^^H By Dr. J. H. AVBLINO, Chairman 44—5 


^^H Election of Council and Officera for the year 1881 


45 


^^H Annual Address of the Pi'esident. William S. Plai- 




^^B fair, M.D. ..... 


"j 


^H March 2Qd, 1881— 


d 


^^H Interatitial Fibroid caiieing Retrofleiion, shown by 


H 


^^M Dr. Godson for Dr. Dbwae 


03 ■ 


^^H Inaugural Addreea of the President (J. Matthews 




^H Duncan. MD.) .... 


01 


^H VIU. On the Bo.caUed " Missed Lalmur " with a case in 




^^M illnatration. By Robert Babner.M D. (A<1journod 


J 


^^M debate on, eee page 110) 


8M 


^H April Cfl), 1881— 


^ 


^^H Dermoid Cyst of the left Ovary, shown by Mr. 


^^1 


^^^^ KnowsleyThobnton 


I^H 


^^^B Microscopic Sections of a Dermoid Ovarian Cyst, 


^^1 


^^H shown by Alban Doban, F.R.C.S. 


1 



IX. Cctae of Extreme Arrest of Development of the 
Genito -urinary Tract in a FemaJe Pajtna. By 

AiBAN DOB&N, P.R.O.S. 

Culculi embedded in Female Urethra, Bhown by the 
President {Dr. J. Matthews Ddncan) . 

Fallopian Qeatation, Uteraa and appendages, shown 
by Dr. Godson for Mr. Hopobopt 

Antefleied tTterua, shown by Dr. Hates 

Adjourned Diacuaaion on Dr. Robert Babhes' paper 

On the so-called " Miaaed Labour," with a case in 

illustration . . . . . [ 

X. A case of Delivery throug-h an Imperforate Vagina. 

By Heiwood Smith, M.A., M.D. Oxon. . . : 

XI. A case of Imperforate Vagina. By Pkbcy Bocltok, 

M.D., M.R C.P. Lond. . . . . : 



Placenta from Triplets, shown by Dr. Galabin for 
Dr. John Bahbktt .... 

Abnormal attachment of Placenta to the Cerebral 
Membranes, shown by Dr. Galabim for Dr. Johh 
Basbett ..... 

Pessaries of Zylonite, shown by Dr. Mbadows 

Leiter'a Temperature Regulator, ahown by Dr. God- 
son ..... 

Fleshy substance discharged from Uterus, shown by 
Dr. Cleveland . ... 

XII. Case of Phlegmasia Doleas with Lymphatic Varit. 

By J. Matthews Duncan, M.D. 
XIII. A case of extra-uterine, associated with intra-uterine 
Flotation, in which alidominal section was per- 
formed. By Alfeed L, Galabik, M.D., P.E.C.P. 
XTV. Statistics of Midwifery in private practice. By 
Geoeoe BiaDBN .... 

June 1st. 1881— 

Depression of Child's Head by Forceps : presentation 

of cast by Dr. Godson . . . : 

Histology of Cancer of the body of the Uterus, micro- 

sf'opic sections shown by Dr. Galabim 
Specimen of Utero-vagioal Rupture : — Placenta 
PriEvia, Multiple Fibroids with deformed Fretus, so- 
called Cretinoid, shown by Dr. WlLTSHIBB 
VOL. XXIII. e 



J 



CONTENTS. 



Cyst of the Great Omentum, shown by Mr, Alb&n 
DOBAH for Dr. Bantock 

MavsliairH Patent Sectional Feeding Bottle, shown by 
Dr. Godson ..... 
XT. Notes on a case of Placenta Pncvia, complicated by a 
large Myoma. By J. Kickinbotham. M.D. 
XYI. Note on the sO'Called "'Lithoptodion," being a Sup- 
plement to the Antbor's paper on so-callod " Missed 
Labour." By Robeki Bianes, M.D. 

July 6th, 1881— 

Instrument designed by Dr. 0. DuNCiN, of Rome, to 
meaaure the amonat of flexion of the Uterus, 
shown by Dr. Fancourt Babhes 

Anencephaloid Fcetus, shown by Dr. Pops . 

A Malformed Heart, shown by Dr. Godson for Di 
Obonk .... 

An Umbilical Oord in a state of Cystic Degeneration 
shown by Dr. Godbok for Dr. Cbonk 

Surgical Pocket-ease, shown by Dr. Godbon for Mr. 
Aen OLD Thompson . 

Report on Dr. Cleveliind'a specimen {see page 132) by 
Dr. Galabin, Dr. J. Williams, and Dr. Ci.bvk- 
LAND .... 

Xyn. Non-capsulated Fibroids, resembling retained Pla- 
centa. By James Bkaithwaiie, M.D. . 
XTIII. A case of- Pregnancy complicated by Dancer of the 
CuTTix TJteri, followed by Pyiemia asaocifttod with 
symptoma simulating Diphtheria. By Alfred L. 
Qai^bin, M.D., P.R,C.P. 
XIX. Notes on the Dissection of a Malformed Child. By 
W, Lbnton Heath, M.B. Loud., F.B.C.S. 

October 5th, 1881— 

Anenoephalous Foitua, with Spina bifida, shown by 

Mr. P. Wai.Ia.CH .... 

Blighted and Atrophied Embryo, shown by Dr. 

Hkkkan ..... 
Polypi Uteri, ehown by Dr. Edis . 
Cysts irom the Labia minora, shown by Dr. Wilt- 

8HIRB < - . . . 

FcelaJ head, plaster casts of, shown by Dr. Bbuhtom 



CONTEWTB. 



Periodical discbarge of Membrane in Cervical 
Endometritis, microHCopioU sections of, shown by 
Dr. Galabin . , . 1 

XX. On the Relation of AuteQexion of the Uterus to Dja- 
menorrhma. Bj G. Ebnest Herman, M.B. Lond., 
M.R.O.P.Lond., F.R.C.S.Eng. . . . I 

November 2nd, 1981— 

XXL BemovaJ of a, large Fibrous Polypus. By HetwoOD 
Smith, M.D. . . . . . ! 

Spring Pessaries, shown by Mr. Bevebley Cole . ; 
The late Dr. McOlintock [Motion of Condolence on 
his death] . . . . . 1 

XXll. On Shortness of the Cord as a cause of Obetmction to 
the Nutural Progress of Labour. By J. Matthews 
Dhkcan. M.D., P.B.S. Ed. . . . 1 

XXm. Twins : Short Funis in both. By J. BaAXTOW 

HicKB, M.D. Load., F.R.S. . . . 1 

December 7th, 1881— 

Ovarian Tunionr, shoivn by Mr. Knowbley Thobn- 

Trauslacent Sac. microscopical preparations of, shown 
by Dr. Herman . . . I 

XXIT. Case of Conjoined Twins. By Percy Boulton, M.D., 

M.H.C.P. Lond. . . . . : 

Fibroma of the Utema, shown by Dr. Hkywood 
Smith . . . . . ; 

Fallopian Tube Pregnaney, shown by Dr. Matthkwb 
Duncan . , . . , 1 

Epillielioina of Oerruc with Pregnancy. By Dr. 
Edis , . . . , ; 

XXT. On the Normal and Pathological Anatomy of the 
Qanglion Cervicale Uteri. By N. W. Jabtreboff 
I. The Treatment of Spasmodic Dysmcnorrboia and 
Sterility by dilatation of the Cervical Canal with 
graduated Metallic Boagiea, with notes of five 
snccessfiil cases. By CI.XMBNT GoDSOH, M.D., 
M.B.C.P.Lond. .... 



299 
313 

1 



PLATES. 

I. Fading lymphatic patch of Left Thigh (Dr. Matthews 
Duncan) ..... 

II. Skin crack patch of Bight Thigh (Ditto) 

in. Viilona Degeneration of the Endometrium (Dr. Mac- 
Galluh) ..... 

IT, Fig. 1.— Pelvis of a newly-bom Female Child. Fig. 2.— 
Two Ganglia in one microscopical aection (Dr. N. W, 
jASTaEBOFF) ..... 
Kg. 3.— Part of a normal Ganglion. Fig. 4.— Part of a 
pathologically altered Ganglion (Ditto) 



Woodcuts. 

I Kodification of Hodge's PesBary (Dr. Hbnbt Gervis) 
I Tripartite Vagina (Dr. Pebct Bodlton) . 
\ Cyst of the Great Omentum, showing the diapoaition of the 
Peritonenm as discovered during the operation (Dr 
Bantock) ...... 

I Case of Malformed Heart (Dr. Clement Godson) . 

Fig 1. — Shows the normal d<!velopment of the Aorta 

and great vessels. 
Fig. 2.— Shows tb« change that occarred, and the 
probable mode of its development. 
Spring Pessaries (Dr. Beteblhy Cole) 
P Spring Anteversion Pessary (Ditto) 
I.Ckinjoined Twins (Dr. Pkect Boulton) 
lletallic Bougies (Dr. Clement Godson) . 
« of Dilators (Dr. Olkmbkt Goi»on) 



VOL. xnn. 



ADVERTISEMENT. 

The Society is not as a body responsible for the facts and 
opinions which are advanced in the following papers and com- 
munications read, or for those contained in the abstracts of the 
discussions which have occurred, at the meetings during the 
Session. 



59, BiSNSBS Stsbbt. 

LiBRABY AVD MUSEUM, 

291> BsQENT Stbbbt> W. 



OBSTETRICAL SOCIETY 



LONDON. 



SESSION 1881. 



JANDARY 12tb, 1881. 



William S. Plavfaib, M.D., F.R.C.P., President, i 
Chair. 



Present — 31 Fellows aud 4 visitors, 



Books were presented hy Dr. Fancourt Barnee, Dr. 
Ramello Condido, Dr. H. Fritach, Dr. D. H. Goodwillie, 
Dr. Leopold Herzig, Drs. A. Hegai- and R. Kalteubach, 
Dr. Edw, W, Jenks, Dr. E. Henry Kisch, Dr. Francesco 
Macari, Prof. Carlo Minali, Dr. Paul F. Mimd6, Dr. B. 
F. Schttltze, Dr. Alois Valenta and Dr. John Williams ; 
the Clinical Society, tho Incorporated Law Society, the 

I Edinburgh Obstetrical Society, and the Medico-Cbirur- 
gical Society of Modena. 
Soc 
Bol 
(D. 
Alf 



The following gentlemen were elected Fellows of the 
Society : — James Hair, M.D. (Peterborough) ; Jamea'| 
Robert Jones, M.B. ; John Fisher Le Page, L.R.C.P. Ed. { 
(Durham); WilUam Henry Netherclift, M.R.C.S.; and 
Alfred Thomas Bowortb, M.R.C.S. (Grays, Essex). 

VOL. xmi. 1 



BXPOUATION OF VESICAL MTJCOtrS MEMBRANE, i 



By ALB4.N D0R4N. 

Wb have here before ua about eight square ioclies of the 
moBColar and mncons coatB of a female bladder. The 
mnscDlar coat looks ragged, as nsual, and the mucous 
membrane is of a dirty brown colour, covered with white 
pstohes which feel gritty to the touch, for they are deposits 
of insoluble phosphates. On placing the membrane 
against a firm surface and pressing a sound against one of 
these patches, this grittiness will be evident to the touch 
through that instrument j such is often felt in sounding a 
diseased bladder, and sometimes taken for the surface of a 
calculus. 

The patient was a married lady, set. 31, under the care 
of Mr. Roche Lynch, of Bayswater. She had always been 
hysterical, and before marriage was subject to difficulty in 
micturition. In November, 1880, she was delivered of a 
first child, which was very large, weighing ten pounds. 
The labour lasted seventeen hours, aud finally, after 
drawing off the urine by means of a catheter, the forceps 
were applied and the head brought down with considerable 
difficulty. The perineum was ruptured by the passage of 
the shoulders, but was stitched up at once. A small 
quantity of urine passed naturally about seven hours after 
labour. During the week after delivery it appears that 
there was"|great difficulty in systematic use of the catheter, 
owing to the resistance of the patient herself, and also on 
account of the state of the perineum. At this period she 
sometimes did not pass her water for five or aii hours. 
On the tenth day all the symptoms of cystitis appeared, 
with frequent micturition. The urine was ammoniacal and 
mixed with blood for a day or two, all power of voluntary 
contraction of the bladder at length ceased, and iincon^ 
trolled incontinence of urine ensued, so that a vesical 
fistula was suspected. On the twentieth day the nurse 



I 



ary H 

on- ^H 

leal ^H 

rse ^H 

AM 



I 



EXFOLIATION OF VESICAL MOCOOa MEMBRANE. 3 

found a slough of large size, which had been discharged 
not only without pain, bat without the patient being even 
aware o£ what had occurred. Smaller pieces continued to 
pass, and three days later Mr. Spencer Wells, who has 
presented this specimen to the Museum of the College of 
Surgeons, examined the patient and declared his opinion 
that the substances passed were sloughs ot the mucous 
membrane of the bladder. Her condition then rapidly 
improved, and in a few weeks she regained considerable 
power over her bladder till she at present is conscious of 
slight spasm in passing urine. 

In a memorable discussion at a meeting of this Society 
in 18G1, Mr. Spencer Wells remarked how it could be 
practically demonstrated, from a specimen he theu exhi- 
bited and from another shown by himself at the previous 
meeting, that cystitis and sloughing of tho vesical mucous 
membrane after labour might be due to two distinct 
causes. One was mechanical injury from the pressure of 
the child's head or of tho forceps during labour ; the 
other cause was retention of urine. In this case the 
labour was lingering, forceps were used, and there was 
subsequent retention of urine. Considering the late- 
ness of the commencement of distinct symptoms of cystitis 
after labour, it may appear at first sight as more probably 
due to retention than to injury of the bladder during 
parturition. Yet the difficulty in delivering the head of 
tho fcetns, which was very large, and the fact that Mr. 
Bocfae Lynch believes that, from the first, there were 
always " some obscure symptoms referable to the bladder" 
mnst, I believe compel us to attribute the sloughing of the 
vesical raucous membrane to injury. During her illness tho 
patient was subject to conditions which rendei'ed any decep- 
tion, by the introduction of membrane from an animal 
[as in Dr. Barnes' case), impossible as well as improbable. 

Dr. OoDBDN referred to a specimen in the Museum of St. 
^v Bartholomew'a Hospital of a complete cast of the mucous mem- 
^h brane of the bladder of a woman, foUowing cystitis in connection 
^H with retroversion of the gravid uterus. Abundance of muscular 



I 



4 THE COMPARATIVE AJJATOMT OP THE 

fibres were to be found at tlie back of the exfoliated membrane. 
The patient was under Dr. Godson's care, and wheu seen a year 
or two afterwards had a contracted bladder. 



THE COMPARATIVE ANATOMY OF THE 
LYMPHATICS OF THE UTERUS. 

A COMMUNICATION oo this snbject was made by Dr. George 
Hoggan, and illustrated by a nnmber of microscopical 
specimens and camera lucida drawings, being the material 
accnmnlated jointly with his wife (Mrs, F. E. Hoggan, 
M.D.) in the course o£ a lengthened research. 

Special prominence was given to demonstrations of the 
lymphatics of the uterine mucosa, as all investigators had 
hitherto failed to discover them, and had finally come to 
the conclusion that they did not exist there. Examples 
of these in Ihe sheep, goat, pig, and mare were exhibited, 
those of the latter animal being specially interesting, on 
account of the superficial position of the terminal twigs. 
These lymphatics were divisible into two categories, deep 
and superficial. A deep layer, formed by a dense plexus 
of valved vessels spread out like a cactus plant on the 
attached surface of the mucosa; these pierce that tissue 
and divide into very many smaller vessels, the superficial 
category, which pass close to the lining epithelium either 
as cuU-de-aac, like the solitary lacteal on a villus, or rami- 
fying as sinuous channels immediately underneath the 
epithelium. Against these terminal lymphatics the uterine 
glands lie like so many leeches, there being no tisane 
intervening between gland and lymphatic walls. Passing 
to the lymphatics of the uterine muscularis, exception was 
taken to the term subserous lymphatics, those vessels 
being both anatomically and physiologically the lymphatics 
of the longitudinal layer of muscle on its outer surface. 
They appear merely as small twigs which crop up here 
and there through the musculature, and after turning over 
one bundle or lying between two for a short distance. 



I 

I 



^B refl 



LTUPHAT1C8 OF THB DTEEUS. 5 

sgaiu pass down through the muscular layer to join the 
portions of the plexus on the inner surface, which in 
appearance closely resembles that on the outer aarface. In 
some animals, the mare for example, no lymphatics are 
ever seen on the serous aspect of the muscle, owing appa- 
rently to the fact that many small irregularly placed 
bundles of smooth mascle fibres (the nerve cords of Lee 
and Snow Beck) lie between the loDgitudinal layer and the 
serous surface. This point waa further explained by refer- 
ence to the true subserous lymphatics in other abdominal 
organs, and especially by a microscopic specimen of the 
subserous lymphatics of the ovary, this organ in that 
respect presenting a strong contrast with the uterine sob- 
seroaa. On either surface of the circular muscles the 
lymphatics lie as closely packed lines of dilated valvular 
sinuses parallel to the muscular bundles and in a condition 
capable of great elongation or distension of pregnancy 
without further development. The deep lymphatics of 
the mucosa are given off from the channels of the inner 
side of the circular muscular layer. Attention was also 
directed to the presence of great cell-lined spaces lying 
like Gynovial cavities between the mucosa and the muscu- 
l&ris. The specimens were mostly prepared with silver 
and gold aolutions. The causes of errors produced in 
former investigations by means of the injection method 
were also explained, and photographs of spurious lym- 
phatics intentionally produced, as well as photographs of 
the real lymphatics which had been taken direct from the 
preparations under the microscope by Mr. Francis Fowke, 
were handed round the hall for inspection and comparison. 



Mr. Knowblkt Thornton aaked Dr. Hoggan whether he bad 
found any evidence of communication betw»n the uterine lym- 
phatics, and the aac ot the peritoneum. Whether he had been 
able to demonstrate tht' stamata described by aome uuthoriticB, 
and whether ho beUeved in their eiiBtcncc. 

Mr. DoBAK asked for the opinion ot Dr. Hoggan on certain 
researches made two years since, in Paris, with regard W the 
lymphatics of the uterus. The corclusiong, at variance vrith Dc. 



6 DOUBLE OVAEIOTOMY, 

Hoggan's opiDions, were that a free subperitoneal aterine plexus 
of Ij'mphaticB existed ; it was also stated that the "stomata" 
marked the site of old endothelial cells in a state of involutioa 
— edged out ia fact by the younger cellB. 



DOUBLE OVARIOTOMY. 

(Under tho eaie at Dr. Lbdusd, Ciuuberlaiid IcSramry, Carlisle.) 
Dr. Matthews Duncan exhibited two ovaries remoyed 
by Dr. Lediard in a case of double ovariotomy, in whicli 
there was auepicion of malignancy. Dr. Lediard had 
furnished the following report : 

" Jane P — , set. 55, was admitted into the Cumberland 
Infirmary on August ith, 18S0, under the care of Dr. 
Lochie, and was transferred, for surgical treatment, to me. 
Patient is a widow, has bad one child ; she is a small, 
spare woman, wttb sallow complexion, but with no 
marked cachexia. She states that several months before 
admission there was occasional pain in the left iliac 
region. Five weeks before her admission her friends noticed 
that her abdomen was largOj and she then began to fail in 
strength. Three weeks before admission her feet and legs 
began to swell, and her abdomen became gradually larger, 
and when first seen her girth was thirty and a quarter 
inches. On the left side of the abdomen a movable 
tumour was felt springing from the left iliac region, 
floating almost in ascitic fiaid. 

" The uterus was depressed and jammed back against 
the rectum, and the cavity of the pelvis was filled up by 
a rather hard substance. The sound passed for one inch 
only. Tapping the peritoneum was performed on foor 
occasions, the largest quantity obtained at one time being 
eighteen and a half pints, when it was found that there 
was a tumour on tho right side of tho abdomen, much 
deeper seated than that on the left ; this tumour was also 
lobulated, somewhat hard, and moved with the uterus. 



DOOBLE OVAEIOTOMT, 7 

"On December 24th the girth was thirty-five inches. 
Ovariotomy was performed upon each side. Aiter the 
ascitic fluid had escaped, the teEt tumour was foand to have 
no adhesions, and a very short pedicle, which was ligatured 
with carbolised ailkj dropped iu. 

"The right tumour was adherent all round to uterus, 
bladder, and pelvic cavity ; these adhesions gave way 
readily enough ; the short pedicle was also ligatured with 
silk, and the incision, three inches in length, was then 
stitched np, the operation having been conducted with 
strict antiseptic precautions. The patient is now, January 
11th, 1881, conTalescent. 

" Sections of the left ovary cut by Dr. Veitoh, hons^- 
surgeon, show the structure usually met with in these 
cases. 

" The tumours are multilocular cysts with a very small 
preponderance of flaid contents. The left ovary weighed 
twelve and a quarter ounces, aud the right one fifteen and 
a half ounces. 

" The ascites was really the chief feature in the clinical 
history of this case, for, although the left tumour could 
always be felt, yet the right one only came into reach 
when the peritoneal cavity was drained. 

" The fixation of the uterus and the somewhat hard mass 
filling up the pelvis and displacing the uterus, seemed to 
point to there being a mtiliguant element in the case, but 
this happily a section of one tumour has disproved. 

"Koberle has had 12 per cent, of his cases double 
operations, Keith -5 per cent.. Wells fi per cent., and 
most writers agree that the danger in such is doubled ; 

I here, however, the adhesions, though extensive, were not of 
ft serious nature, and not one blood-vessel required ligature 
save in the pedicles." 
on 
8l 
o£ 



I 



JSt. Khowslet Thobhtor after seeing the Bpecimone remarked 

\ on their airailarit; to a specimen exhibited by tit. Doranfor Mr. 

f SiMDcer Wells at the Pathological Society, and called a papilloma 

of the Fallopian tube. There was in that case also eiceanve 

effusion of serum into the peritoneum (ascites), and he thought 



8 A SYPHON DODCHB, 

a verj iiitereBting queatioa was raised by these specimens. Did 
the fluid gather in the peritoneum as a result of the mechanical 
irritation caused by the presence of these semi-solid tumours, or 
was it a secretion from their interior, which escaped through 
some minute aperture, or through a rupture into the tube, as he 
beUeved was the case in Mr. Wells's specimea ? 

Mr. DoBAN contrasted this case of ascites ^nth others vhere 
still less ovarian disease existed, as Gusserow and Ebcrth's case, 
where there were free papillary growths on the surface of the 
orarles, and a case under the care of Dr. Bantock, where the only 
evidence of any source of peritoneal irritation was chronic inflam- 
mation of both ovaries. After oophorectomy the distension dis- 
appeared. 



A SYPHON DOUCHE. 

De. Edis exhibited a simple form of syphon douche for 
the employraent of hot water vaginal injections. It con- 
sisted of a piece of india-rubber tubing eix feet in length, 
half an inch in diameter, with a piece of leaden tube about 
two inches from one end so as to ensure it sinking in the 
water, and a vaginal nozzle the other. A second piece of 
lead tubing was placed about fifteen inches from the other, 
so as to prevent the india-rubber tube becoming bent at 
the part where it emerged from the spout of the can. To 
this an elastic band was attached to secure the tube to the 
spout and prevent its falling out of the cau. An ordinary 
clip to compress the tube, or a small tap inserted in the 
length of the tubing, served to shut off the water when 
requisite. A bath can, capable of holding two to three 
gallons, is then filled with warm water, the temperature 
being regulated as desired from 90° F. to 110° or 115° P. 

The end of the tube with the leaden tubing is then 
passed from outside through the spout of the oan, the 
remainder of the tube being pushed iu, so as to allow it 
to become filled with water as far as the vaginal nozzle. 
On now compressing the tube and withdrawing it from the 
c^an all but the final eighteen inches or bo, taking care to 



I 



I 



I 



A BTPHON DOCCHE. 9 

hold the nozzle below the level of the wiiter in the can 
and removing the pressure, the syphon action is produced 
Bnd the water flows freely. The clip is then applied to 
the tobing so as to prevent the water flowing until 
wanted, or the tap is turned, as the case may be, and the 
douche is ready for use. 

The can is then placed upon a cheat of drawers or other 
article of fnrniture close to the bed, so as to bo some two 
or three feet above the level of the bed, and the tube put 
within reach, A pillow is then placed at the edge of the 
bed so as to raise the hips, a tub, footpan, or other 
receptacle for the water, on the floor beneath, and two 
chairs just in front. A piece of mackintosh is employed 
to cover the pillow, the lower portion hanging down into 
the vessel beneath so as to prevent the bed from being 
wetted, to convey the water away as it flows from the 
vagina. The patient now lies on her back with her hips 
resting on the pillow close to the edge of the bed, and 
her feet on the two chairs. The knees are covered with 
a couple of shawls or small blankets, and the body also 
protected from cold. The nozzle at the end of the tubs 
being now gently inserted into the vagina and directed 
backwards behind the cervis into the posterior cul-de-sac 
the clip is removed or the tap turned, and the water 
allowed to flow into the vagina. 

A tube such as here described allows a gallon of water 
to flow through it in about four minutes, so that an 
ordiuary bath can, which holds three gallons, will enable 
the patient to keep np a continuous supply for from ten 
to fiftet;n minutes. 

The advantages gained were the simplicity and iuez- 
pensiveness of the apparatus, the only requisites being an 
ordinary bath can sach as met with in every well-furnished 
house, and six feet of tubing. There was no need of 
having a tap or spiggot inserted in the lower part of the 
can, no skilled nurse was necessitated, the patient was 
quite independent. 

Emmet states that " a steady stream is never as ser- 



^m quite u 
^H Emn 



10 



INCOMPLETE EDPTUBE OF VAGINA. 



vicBable as the interrupted current from a Davidson's 
syringe, the jet acting as a. stimulus to escite the blood- 
vessels to contraction ;" bat this is open to question. It 
is the continuous application of warm water that produces 
the good effect. Besides, it is not every private patient 
who is in a position to command the services of an ex- 
perienced nurse morning and evening, nor would many 
ladies care to ask a servant to perform such a duty, and 
it is impossible for the patient herself to inject two or 
three gallons of hot water into her vagina when lying on 
her back. 



INCOMPLETE RUPTUBE OF VAGINA, DISCO- 
VERED POST MORTEM. DEATH FROM SEPTI- 
CEMIA. 



Dr. Champneys showed the uterus and neighbouring 
parts of a primipara, fot. 34, who died in St. George's 
Hospital in consequence of an incomplete rupture of the 
vagina. 

Tho fcetus apparently died about the end of the sixth 
month. The patient was admitted at the end of the 
seventh month for retinitis albumiuurica. Labour camo 
on spontaneously the day after admission, and was easily 
completed in 6ve hours in tho first cranial position. The 
child was apparently of six months' growthj macerated 
and dropsical, not putrid. No bfemorrhage or unusual 
symptoms. Temperature rose at the end of the second 
day, and cystitis supervened with severe pain in the hypo- 
gaatrium on the third day. 

Examination on the seventh day discovered a quantity 
of clots in the vagina, tho lower ones slightly offensive; 
removed by tho fingers. Two patulous cavities felt, one 
behind the other, separated by a small bridle or cord 
running more or less transversely, and at first feeling like 
tho partially detached anterior lip of the cervix ; but both 



I 

I 
I 



INCOMPLBTB BPPTUSB OF VAGINA, 11 

cavities were afterwards foaiid to be posterior to the 
cervix. No bowel or other evfdence of rapture into the 
peritoneal sac discovered. Uterine injections of carbolio 
acid, one in forty, ordered. 

On the eleventh day the breath was noticed to be 
sweet. Diarrbcea commenced, and continued nncheoked 
by any means till death. The condition of the urine and 
sight improved, bat the abdominal pain continued. No 
more clots were formed, and the nteruB contracted firmly. 

Death occorred on the sixtfienth day, 

Atiiopatf. — No deposits in any organ. Purulent peri- 
tonitis. Cystitis. Under the peritoneum, in front of the 
last two lumbar vertebrte and promontory of sacrum, was 
a layer of extravasated blood. Finger in vagina felt 
the " bridle " described behind cervix uteri. Peritoneum 
of Douglas's pouch intact. A large abscess in upper and 
outer part of left broad ligament, extending in direction 
of round ligament. On removing uterus, vagina, and 
bladder en maase, a round rent was found immediately 
below the os nteri in the posterior wall of the vagina, 
about the eiite of a florin, divided into two by a transverse 
liand, now broken; the edges of the rent consisting of the 
inner layers of the vagina overhanging. From this 
situation effused blood can be traced round the rectum to 
the posterior layer of Douglas's poncb and over the pro- 
montory of the sacrum. The rent communicates neither 
with peritoneum nor rectum. The uterus shows nothing 
but the usual healthy post-partum appearances. 

Ilem-arlc». — There was no history of any injury. The 
labour was easy, the child small and macerated. There 
were no signs of Btonosia of the vagina or cervix, nor any 
history of such. There was a history of a sudden pain 
some five weeks before admission (in the sixth month), 
oommoncing at the navel and travelling round to the left 
bypochondrinm and back, lasting seven hours, then going 
oS; but this date does not correspond with the recent 
appearance of the rupture. There seems no reason to 
attribute the rupture to nutritional impairment due to 



12 



COMPtETB EXTTEPATIOW OF TSB UTERUS 



I 



the albuminnria. The ruptare probably occurred intra- 
partum, but its cause is obscure. (Cf. Breisky in Pitha 
and BiilrotVs 'Handb. der AUgem, u. Spec, Chir.,' Band 
iv, Lieferung 7, 1879, p. 88 et aeq.) 

Dr. WiLTBHiBE said Dr. Champneys' caae reminded him of 
one he bad aeen in coiiBiiltation with Dr. Owen Roberta, where 
also a rupture had taken place spontaneouBly, the left lower 
segment of the uterus being ruptured over an eitent of eereral 
inches. The patient had met with an accident a few days pre- 
viously, and waa rather precipitately delivered, before medical 
help arrived, of her fourth child. Dr. Boberta subsequently 
found a rent in the left side of the cervii. Dr. Wiltshire also 
found this chasm when he examined the patient, and there was 
also a lar^ effusion of blood on the left side between the layers 
of the broad ligament. The patient recovered perfectly. Dr. 
Wiltshire also referred to a case of utero-vaginal laceration 
already recorded by him in the Society's ' Transactions.' 



COMPLETE EXTIRPATION OP THE UTERUS WITH 
BOTH OVARIES, WEIGHING TEN POUNDS. 



RECOVERY. 



By Thomas Chambers, 



a coxaiTLTtNa 



LThb object of this short paper is not to enter into or 
discuss the complex question of uterine fibroids, but 
simply to record a typical case without comment, leaving 
the question open for discussion, if the Fellows of the 
Society should be of opinion that any practical result can j 
bo attained. 
Jane S — , set. 43, single, was admitted under my care I 
May 24tb, 1880. Up to ten years ago she had always I 
enjoyed good health, had meustruated with regularity and I 
vrithout pain from the age of fourteen. In 1870 she I 
noticed for the first time a lump in her right groin, aa I 



WITH BOTH 



13 



im 

■ Ut 



large as a fall-sized egg, but as it did not in any way pain 
or annoy her, no notice was taken of it. It continued, 
however, to grow slowly for abont five years, by which 
time it had reached the median line, its upper margin 
forming a well-marked prominence above the pubis. Up 
to this time no anpleaeant symptoms had presented them- 
selves, but now her periods, which had hitherto been both 
regular and painless, became excessive, both as to quantity 
and duration, as well as painful. She consulted a doctor, 
who prescribed for her unsucceasfally. 

As time went on her suffering and blood-losa greatly 
increased, so that her health began to suffer considerably. 
For two years she attended different institutions, but with 
little real beneBt. She became dim-sighted, had a yel- 
lowish haze always before her eyes, with a constant 
Ifloftting about of black spots. 

Jn April, 1876, she was admitted into a London 
iho^tal, where she remained nntil the following Jane. 
No local treatment was adopted, and she was discharged 
with but little amelioration of her most urgent symptoma 
— excessive pain and hiemorrhage. 

From this time to January, 1880, she continued to take 

tonics, cod-liver oil, &c., but was not under any special 

treatment. It was at this period she first came under my 

^L notice. She declined to come in, and was treated as an 

^H out-patient about five months, during which period she 

^F took a considerable amount of physic, including those 

remedies most renowned in the treatment of uterine 

fibroids, but without any material benefit. She became so 

^^ thin and weak that she could no longer continue to attend 

^^U as an out-patient and, as she was entirely dependent upon 

^H her friends for her support, she determined to come in, 

^H prepared to submit to any kind of treatment that might be 

^H deemed desirable. This course, however, was not adopted 

^H without many and serious misgivings on her part as to the 

^H resnlt. When admitted, she was emaciated to a remark- 

^H able degree — a mere shadow. This extreme leanueee, 

^H together with the mad-yellow tint of her skin and the 



1(S COMPLITB BXTIEPATIOK 0? THE DTBEUS 

median line. The peritonenm was mucli thickened and 
more hardened than is usually observed in abdominal sec- 
tions ; when opened, about half a pint of ascitic fluid 
escaped. On introducing- the hand the tumour was ascer- 
tained to be the uterus, ovoid in form and very elastic, 
and occupying the whole abdominal cavity, its upper sur- i 
face being in juxtaposition with the liver and stomach; no 
adhesions. Free pulsation of what appeared to be arte- 
ries of great size was very distinct. 

Aa the tumour could not be reduced by puncture, the 
incision was extended to eleven Inches, and the tnmoor 
lifted out of its bed. 

Tho vessels travelling the broad ligaments were 
numerous and of large size ; the cervix uteri was flattened, 
and of remarkable donaity. On the left side a large arte- 
rial trunk could be felt coursing its way up to the tumour. 
The broad ligament on either side, with its vessels, were 
carefully separated from the side of the cervix, transfixed, 
and tied with a twisted silk ligature. This b 
accomplished, my strong parallel clamp was placed 
between the ligatures below and the tumour above, and 
tightly screwed home. The abdominal opening was now 
carefully protected, and the uterus separated at the junc- 
tion with the cervix. For a few minutes after the separa- 
tion there was no hiemoiThago, and it was supposed that 
the whole of the vessels communicatiog with the tumour 
had been secured in the ligatures embraciug the broad 
ligaments, but presently a large stream of arterial blood 
shot up from the artery which had previously been noticed 
coursing up the left side of the cervix ; it was at once 
secured and ligatured. This momentary loss represented 1 
all the arterial blood lost at the operation. 

After the bleeding artery had been secured, the cervix I 
uteri was transfixed by a double ligature of twisted silk I 
(No. 35), care being taken that the two ligatures should I 
croB.'i ; they each embraced a broad ligament below the I 
ligatures specially applied to these structures as an addi- 
tional security against haemorrhage. When both were in J 



WITH BOTH OVARIKB. 



17 



I 



I 



pOBihon and ready to be tightened the clamp was removed. 
After waiting a few minutes they were finally secured, cut 
off short, and the stump quietly replaced in the cavity, 
which was carefully sponged out, the aides of the wound 
brought together and secured by twenty silk sutures; it 
was necessary to place them close together in order to 
restrain a general oozing from the edges of the wound, 
which had come on after the separation of the tumour. 
The wound was covered with a strip of lint smeared with 
vaseline, and the abdomen secured as after ovariotomy. 
By 6 o'clock the effect of the ether had passed off, and as 
she felt a good deul of pain in the abdomen a morphia 
suppository (gr. !;), was put into the bowel, which relieved 
her considerably. 10 p.m. — The pain was still marked, 
though much less; no sicknese; temp. 100, pulse 96, 
resp, 24; repeat suppository. The temperature and pulse 
were recorded by myself twice daily, occasionally three 
times, for the first fourteen days, and once daily for the 
next seven days, when there was no longer any neces- 
sity for it. 

June 23rd {the 21st day}. — Appears quite well, with 
the exception of general weakness due to the emaciated 
and anasmio condition to which she had been reduced 
previous to the operation. Abdomen soft and reduced to 
its natural proportions. Wound firmly cicatrised, the 
vaginal discharge almost ceased. To be removed to 
another room. Temp. 99'7, pulae 86. She may fairly be 
pronounced cured. 

Examination of the tumour proved it to be a lobulated 
white fibroid, the lobular surfaces being held together 
loose cellular tissue, which permitted them to more 
npon each other with facility, thus imparting the idea c 
obscure fluctuation, which led {with other symptoms) t 
the error in diagnosing it to be fibro-cystic. This exami- 
nation clearly indicated what was not so apparent previons 
the operation, viz. the excessive vascularity of the 
uterine walla. 

Vessels of great size were travelling in bundles in all 

VOL. XSJII. 2 



18 



BXTIEPATIOK OP THE UTEEUa WITH BOTH 0VAEIB8. 



directions — the iDouth of one meaanrecl halE an inch — ^many 
vessels between the tumonr and the uterine walls were 
attached to each by a thin stratum u£ fine cellular tisBne. 
The vessels in the lower zone of the nterus were very 
nimieroQs and of large size. 

The deduction to be drawn from these observationfl 
clearly supports the belief that, if any attempt had been 
made to enucleate, the result wonld have been disastroos 
to the patient and sadly disappointing to those having the 
responsibility of the case. 

A retrospect of this case would appear to suggest a few 
points for consideration, viz. : 

1. The length of time a fibroid — even of considerable 
size — may exist without symptoms. In this case five 
years. 

2. The celerity with which symptoms develop after they 
have once appeared. 

3. The inefficacy of medicines to control such eymptoTQS 
when brought into operation. 

4. The difficulty of forming a correct diagnosis in any 
given case of fibroid disease of the uterus. 

5. The practicability, expediency, and safety of extirpa- 
tion in cases where other forms of treatment have failed. 

6. The comparative simplicity of the operation and its 
immunity from the hazards of htemorrhage. 

7. The great vascularity of such growths, and the 
hazards pertaining to enucleation in cases like the one 
here recorded. 

Dr. Heywood Smith remarked that Mr. Thornton used the 
term hyBterectom.y as applied not only to removal of the supr^ 
vaginal portion of the uterus but also to caeoa of fibroid out* 
growths only, whereas he considered that term should be limited 
to amputation of the uterus. Dr. Heywood Smith also con- 
sidered that the operation of oophorectomy was a safer proceeding 
in cases of intra-uterine fibroid, where a patient's life wag 
threatened by flooding and pain than the removal of the utenu, 
or even in some cases than the removal of sub-peritoneal fibroids. 

Dr. BouTH said he had, some years back, tabulated a number 



< 



CHEONIC COHPLBTE rNTBRfilON OP THE UTERUS. 19 

of cases of fibro-cjstic disea§e as compared to pure fibroids of 
the uterus. With regard to the menorrhagia present, to his aur- 
priso he had found whereas menorrhagia waa very common in 
fibroids, it was very rare in fihro-cyatic diaeafie. This circumstance 
if confirmed would help the diagnosis. 



A CASE OF CHRONIC COMPLETE INVERSION OP 
THE UTERUS, SUCCESSFULLY TREATED BY 
SUSTAINED ELASTIC PRESSURE. 

By W. R. BooEBs, M.D., M.R,C.P. 

FBTSICTUt TO TBI SAUARTTAIt BOBPITU >0B WOHIN AUD OaiLSXBK. 

Mea. S. B — , residing near Newnham, Gloucestershire, 
let. 29, had always enjoyed good health, and never had 
any menstrual troubles. Married at 26. Had a child 
two years ago, which was born during the absence of her 
doctor. The birth was followed by great flooding, which 
has continued more or less ever since ; for some months 
it was irregular and very frequent as well as profuse ; 
the last twelve months it has been regular as to monthly 
periods, but very profuBe likewise, so that she has become 
Tery weak, reduced in health and strength, and looks 
very anaemic. About a month after her confinement her 
medical attendant made an internal examination, which 
gave her great pain, but no benefit followed. After 
a long interval he made another equally unsuccessful 
attempt to reduce the inversion, which was the cause of 
these losses. At the end of the second year {April 1879} he 
advised her to come up to a London hospital for treatment, 
And then stated the nature of her malady. 

After a day's rest in the Samaritan Hospital I made an 
examination and found a large polypoid mass in the vagina 
B9 large as a turkey's egg. I was able to pass my finger 
round and above it, and felt a ring-Iikc neck encircling it, 



20 



CHRONIC COKFLETK INyEBStOH OF THE DTEBtTS. 



bat neither finger nor Bonnd conld be passed above a line 
or two throngh what I felt sure was the neck o£ the nteras. 
On passing sound into bladder and finger into rectum 
these were brought in contact above the neck where the 
fundus should be in the normal state of the uterus; the 
tumour in vagina was painful on pressure, bled freely oa 
examination, and by speculum was seen to be covered with 
oozing points of blood from its pores, and it had all the 
characters of a raucous membrane. My colleagues, Drs. 
Routh and Wynn Williams, subsequently examined her i 
and concurred in my view of the case; there was no 
difficulty in the diagnosis. From previous experience of 
three similar cases of inversion of the fundus uteri, and ' 
from reports of cases brought before the obstetric section 
of Jhe British Medical AsBociatiou at Cork, by Drs. Lombe 
Athill, Robert Barnes, John Wallace, and J. H. Aveling, I 
decided not to attempt any other plan of treatment than 
by elastic continued pressnre, which, so ably advocated by ■ 
the late Dr. Tyler Smith, has been frequently successful 
of late years, especially by the use of the repositor invented 
by one of our fellows. Dr. J. H. Aveling, to whom I am 
greatly indebted for the loan of his instruments, and aid 
in placing it. On the 28th of last April Dr. Aveling'a 
" double-curved repositor " was applied to the tumour 
without any difficulty, the bands and straps fixed on body 
and tied by tapes to the elastic rings on the repositor by 
Dr. Avelingj who gave them the required tension. AJi 
opiate suppository was placed in recto. This was at 10 a.m. 
During the day the patient complained of very little pain, 
and at d p.m. the nurse tightened the strings. Patient 
slept pretty well ; water drawn off night and morning. 
When seen at 10 a,m. the following day by Dr. Aveling 
and myself she was very comfortable, saying her pain was 
trifling ; there was but little discharge. The strings were 
again tightened; no suppository used. At 5 p.m, I 
tightened the strings again, which the patient endured 
well. She had no sickness, uo rigors, no rise of tempe- 
rature, and had slept well during the night. At 10 a.m. 



UVEBT IN A CASE OF DOUeLE liTEUUS. 21 

the next day, forty-eight hourH after the first application 
of the repositor. Dr. Aveting met me again. The patient 
now told ns that at about 2 a.m. Bhe had felt great relief, 
Eomething had given way, and the strings had become 
loose. She had slept comfortably. On examiuation the 
repoaitor was found within the uterus, high up, cervix con- 
tracted round it. 

I found no difficulty in removing the cup. By examina- 
tion with finger and sound, the fundus had become restored 
to its natural position, sound entered two and three quarter 
inches. The uterua was injected with water and iodine, 
aod this was repeated night and morning for several days. 
She got rapidly well without a bad symptom, and left the 
hospital on the 8th of May. In this case the repositor 
haii been only applied forty hours when the inversion was 
overcome, not a bad symptom having occurred to require 
relaxation of pressure or removal of instrument. Dr. 
Aveling's double-curved repositor has again been a great 
Giiccess, and I agree with hiiu, "that cases must be very 
rare in which the obstacles to reinversion of the uterus 
are so insuperable as to render ampatation necessary, and 
a a mutilation warrantable/' 



Dr. AvcLiMO stated that since ho hod Invented hia repositor 
lasl year five cases had been succesafully treated by it 



DELIVEKY IN A CASE OF DOUBLE UTERUS. 



By J. MATTHEVfs DuwcAN, M.D., F.R.S. Edin. 



I LAT this case before the Society because it is one that 
occars rarely, and still more rarely is deeoribed. The 
titente was not altogether doable, but, having the outward 



22 DRLn-EEY IN A CASE OF DODCLE UTEEUS, 

appearance, or rather feeling o£ oneneas, poBsessecl' 
cavities separated by a thick wall running in a sagittal 
direction, and extending from the fundus to the internal os. 

C. E — , enjoying fair general health, had had eight 
children naturally, no miscarriage. This, her nluth preg- 
nancy, was healthy, and her ninth child, a well- developed. 
boy, was born a fortnight before the computed time. Tip 
labour was natural and easy, the second stage being com- 
pleted within an horn-. 

She narrates that, in some previous pregnancies, she had, 
about the third and fourth months, copious losses of blood, 
which were regarded as threatened miscarriages, and on 
account of wliich she was kept in bed for several weeks 
at different times. During thia ninth pregnancy she had 
no discharge of blood nor of anything like decidna. 

The placenta came easily away, under moderate supra- 
pubic pressure, about ten minutes after the birth of tho 
child. It was, in shape and contour, natural; not pre- 
senting such characters as it might have if developed in a 
uterine sac* Esamining it, I found the amniotic mem- 
brane apparently entire, but only a part of the chorion 
connected with it. The remaining chorion, detached from 
about a half of the edge of the placenta as it came away, 
was still f ;t idero. The detachment had been easily effected 
in consequence of tho morbid condition of the combined 
chorion aud decidua at this part of the placental edge. 
It was of a light-yellow colour, not thickened, but indurated 
and fragile. 

Tho missing chorion was sought for in the vagina and 
cervis: ; and, as it was not found, the hand was passed into 
the genital canal to search for it in tho body of the utei-us. 
Doing this I found the two cavities of tho uterus. The 
chorion was found in the right or larger cavity, where the 
child had been. The left or smaller cavity had, in every 
respect, except size, the same feeling and behaviour as the 
right or larger. The left or smaller presented no mem- 
brane. 

• See my ' Re*enrciieH in Oliatelriw 



PRKGNASCY WITH DOUBLE UTEECS AND VAOIKA. 



23 



The external contour of the uterus was exactly like that 
of the doable uterns represented in Cruveilhior's plate, 
Livmison 13, Planche 5, fig. I, the right half of the fundus 
being, in my case, larger, and rising to a higher level than 
tho left half, the ontUne of the fundus presenting therefore 
a sinnosity. Both cavities expanded and contracted 
simultaneonsly. When the hand could be passed into the 
right, some fingers only could be passed into the loft. 
When two fingers could be easily passed into the right, 
one only could bo urged into the left. The cavities were 
alike in shape, both having a rounded, conoave, fundal 
roof. 

The cervix was single, natural, relaxed aud loose. The 
firm septum of the uterine cavities ended, at its upper 
part, in a Smooth, broad-edged end. r In the ' Obstetrical 
Journal' for 1873-74 (vol. I, p. 785) I described a 
atems snbseptns occurring in a woman who bad borne 
children. In that case the right uterine cavity was the 
larger and probably the part nsed in pregnancy ; but the 
wall dividing the two cavities did not reach to the internal 
OB uteri. 

The patient, whoso case is above recorded, I examined 
on th(3 twelfth day after delivery, and I was unable to 
find, by simple digital investigation, or by tho bimanual 
method,' anything .abnormal or that could suggest the 
doubleness of the uterus. 



CASE OF PREGNANCY WITH DOUBLE UTERUS 
AND VAGINA. 



By J. Braiton HicM, M.D., F.B.S., 



Sous years since I was asked to see a lady with a tumour 
in the right inguinal region, and as there were symptoms 



24 



TEBTICAL BEPTDX raFEDIKO LiSODB. 



indicating' pregnancj at the fourth month, I was wanted 
to determine whether it were a caee of extra uterine 
foetation, 

I found a rather elongated tamotir in the left groin, not 
extending over the median line, hct reaching up to the I 
flank. In passing the vnlva luy finger came in contact i 
with the edge of a firm eeptum, and it was obvioaa, after 
passing the finger upwards on both Bides, that an os uteri 
existed on either uide. The aterns on the right eide was 
manifestly pregnant, and, of course, was more developed. 

The pregnancy went on to the full term, and she was 
delivered without diiBculty or trouble. Indeed, so little 
abnormal was the labour, that the medical man who 
attended her (uot the sanae who met me in consultation) 
failed to detect the dual condition at the time. Indeed, 
ho was sceptical till I recommended hiin to examine before 
be gave up the caee. When he did so he found it as I 
have described. 



VEETICAIi SEPTUM IN LOWER PAET OF VAGINA 
IMPEDING LABOUR. 



By J. Beaston Hicks, M.D., F.It.S. 

I WAS once asked to assist a gentleman attending a caee 
of labonr. The head of foetus was ready to escape, bnt 
its exit was impeded by a stout band dividing the lower 
vagina. I found a stout, firm band extending from 
urethra to perinteum, stretched over the head and pre- 
venting its expulsion. I pushed it to one side and the 
head passed through at once. On examining afterwards, 
I found it a vertical septum of firm substance, with broad 
attachments extending about one and a half inches up the 



riBEOID TDMOURS COMFLTCATING DDLITEKT. 25 

vagina, aud eridently a rudiment of a double vagina, 
Neither the wife nor husband had noticed its existence. 

I>r. MatthewbDdkcab regarded casesof delivery from double 
uteri as of great interest, and Dr. Hicks's was a fine example. 
Such deliveries would throw light on many points in the 
mechanism of pregnancy and labour. He hoped no one would 
neglect to publish any instance. Cases of delivery when the 
duplicity was only of the vagina were more frequent and 
probably less important. He (Dr. Duncan) had, several years 
ago, published two in hie volume of ' Besearches in Obstetrics.' 



SUPPLEMENT TO A PAPER ON FIBROID TUMOUE 
COMPLICATING DELIVERY. 

By W. S. Platpair, M.D., P.E.C.P. 

Thj nineteenth volnme of our ' Transactions ' contains ft 
paper by me on " Fibroid Tumours of the Uterus Compli- 
cating Delivery," in which I have related several cases of 
this formidable complication of labour occurring in my 
own practice, in two of which the Ctesarean section 
would have been inevitable had the obstacle not been 
overcome by reposition. The difficulties and dangers 
connected with this kind of case are so great, to say 
nothing of the anxiety to the medical attendant, that it ia 
& matter of moment to record as many examples as possible 
for, our future guidance. 

This will, perhaps, serve as an apology for detailing two 
more cases which have since occurred to me, both of which 

I are interesting in their way, and servo to illustrate various 
points in connection with this subject, and which I submit 
as a supplement to my former paper. 
In May, 1878, 1 was consulted by a young lady, who had 
pot long been married, Within three months after 



I 



26 FIBROID TDMOUKS COMPLICATING DELIVERY. 

marriage she had aborted without nny known caase: 
The reason for seeking advice was that she now, and 
ever since she could remember, suffered from extreme 
dysmenorrhcea, the pain being so great aa to compel 
her to remain in bod. The amount lost was also excessive, 
and large ooagula were passed. Ou vaginal examination 
I found that there was a large globular mass, occupying 
Douglas' space, and descending rather deeply into the pelvic 
cavity. The corvix was displaced forwards and jammed 
behind the pubes. The uterine cavity measured 3^ inches 
with the sound. The tjumour was diagnosed to be a 
fibroid growing from the posterior wall of the uterus 
above the cervix, but from its remarkable mobility it was 
thought that it probably had a somewhat narrow pedicle. 
At this time the following note was made in my case- 
book. — " In the event of pregnancy from the position and 
mobility of the tumour, it is far from improbable that it 
would become impacted in front of the head, and, in that 
case, it might form an almost insuperable obstacle to deli- 
very. I cannot but feel that should become pregnant 

the case would give rise to the most serious anxiety," 

Shortly afterwards this lady became pregnant, and her 
case, as was anticipated above, did give rise to anxions 
consideration. I was fortunately able to command the 
best assistance in its management, and I at various times 
had the privilege of meeting several of our leading 
obstetricians in connection with it. I'rom the mobility of 
the tumour some of the gentlemen who saw the patient 
with me thought the tumour might be ovarian, but the 
event proved the original diagnosis to be correct. The 
anxieties it gave rise to became further increased by the 
unpleasant discovery that the patient had a largo amount 
of albumen in her urine. It was decided that no immediate 
steps should be taken, and in the later months of preg- 
nancy, I had the satisfaction of finding that the tumour 
was rising higher and higher in the pelvis, and eventually 
it was almost entirely above the brim. Labour came on 
at term in September, 1879. It was perfectly easy and 



I 



I 



iTBUOID TDMOUEB COUFLICATJNG UELIVEET. 27 

normal in every way. No difficulty was caused by the 
tumour, which spontaneously rose entirely above the brim. 
The uterus contracted firmly and well, and the recovery 
was most satisfactory. 

I have since frequently examined this patient, and, as ia 
ao often the case, the tumour has to a considerable extent 
lessened in size since delivery, partaking of the general 
involution of the uterus. Moreover, it has not again 
descended into its former position in the pelvic cavity, 
being now entirely above the brim. The dyamenorrhosa, 
from which this patient formerly suffered, has since labour 
entirely disappeared. 

The result in this case was a very happy one. The 
spontaneous rising of the tumour above the brim spared 
us the necessity of any active interference ; such a termi- 
nation, however, is rare, and I have not met with it in 
any of the cases I have seen in which the tumour was 
originally situated below the brim of the pelvis. 

The next case was that of a lady, aat. 30, who was sent 
to me in July, 1880, by Mr. Spencer Wells, with a request 
that I should take charge of her during her labour, which 
was expected about Christmas. About two months after 
her marriage, being then travelling in Switzerland, she 
had some pelvic pain, which induced her to consult a 
physician in Zurich, who told her that she bad a large 
fibroid of the uterus. On this she came to London and 
placed herself under the care of Mr. Spencer Wells, who 
verified the opinion which had been given her. After a time, 
finding she was pregnant, Mr. Wells placed her under my 
care, and we subsequently frequently met in consultation 
on her case. The following is the memorandum I took of 
her case on first seeing her : — " The greater part of the 
cavity of the pelvis is occupied by a rounded, somewhat 
nodulated mass, which, by bimanual examination, can be 
made out rising above the pelvic brim. The cervix ia 
pushed forward behind the pubas, and is so high up as to 
be reached with difficulty." It was quite clear that in 
the existing state o£ things delivery per via* nahirnlee was 



28 



FIBROID TDUOnRS COMPIICATINQ DBLIVEEY. 



quite impossible. We decided, however, that the case 
should not then be interfered with, in the hope that, as 
pregnancy advanced, the tumour might spontaneously rise 
into the abdominal cavity, as ao happily occurred in the 
liist case. Mr. Wells and I frequently saw this patient 
together, and in some degree this expectation was realised, 
as the tumour rose to a considerable extent as the utema 
enlarged. Between the seventh and eighth months, how- 
ever, it became stationary, and as it still occupied the 
greater portion of the pelvic brim, and to such an extent 
as to preclude the possibility of natural delivery, it became 
an anxious question as to what should be done. On the 
30th of November Dr. Braxton Hicks met us in consulta- 
tion, and, after deeply an^athetising the patient, we made 
an attempt at pushing the tumour above the brim, in 
which, however, we were not successful. We then 
resolved on the induction of premature labour, believing 
that in any case it would be an advantage to have a child 
smaller than at term. We determined that if when 
labour supervened it was found impossible to deliver, that 
Mr. Wells should perform Porro's operation, and remove 
the uterus and tumour together, believing that this would 
give the patient a better chance than any other pro- 
cedure. 

On the evening of December 1st I introduced a male 
elastic catheter between the uterine walla and the mem- 
branes, and a full-sized sponge-tent into the cervix. Next 
morning, on removing the sponge-tent, the cervix was found 
to be fully dilated, pains occurred at intervals of ten minutes, 
and the head was found to be presenting. I now resolved 
to make another determined effort at reposition, and when 
the patient was deeply anaesthetised I passed my whole 
hand, or rather my closed fist, into the vagina, and made 
strong upward pressure on the tumour. After using a 
considerable amount of force I had the satisfaction of 
feeling the tumour recede above the pelvic brim. I then 
immediately turned the child by the bi-polar method, and 
brought down a foot, being anxious to empty the uterus 



FIBROID TCMOCGa COMPIICATINO DEUTERY. 



29 



before the tumotir was again forced down by tte pains. 
The body passed with great ease, but when the head 
reached the pelvic brim much difficulty in estracting it 
■was experienced, and I thought at one time that it would 
be necessary to perforate. I think it likely that this 
obstrnction was caused by the tumour falling down on 
the brim, and partially occupying its old position. The 
child was apparently stillborn, bnt was eventually resusci- ■ 
tated. The uterus contracted firmly and well, and there 
was no post-partum haemorrhage. The tumour could 
after delivery be made out throngh the flaccid abdomen 
growing from the right posterior surface of the uterus. 
The patient made an excellent recovery without complica- 
tion of any kind. 

This, with two cases mentioned in my former paper, 
makes three cases tliat have come under my observation 
of fibroid tnmoui- occupying such a position in the pelvis 
that had it not been possible to get them out of the way 
the Csesarean section would have been inevitable. Happily 
in all three strong upward pressure succeeded in dis- 
lodging them, Bo that delivery was effected per viae 
naivralesj twice by turning, once by the forceps. They 
teach ns, I think, the hopefulness of such a procedure, 
and the advisability of making a strong and persistent 
effort at reposition, in which an amount of force may be 
necessary which would be quite unjustifiable were there 
any less terrible alternative to be selected than the 
' Cffisarean section. 




I 



ANNUAL MEETING. 



FEBRUARY 2nd, 1881. 

W«. S. Playfaih, M.D., F.R.C.P., President, in the Chair. 

Present — 66 Pellowa and 14 viBitora. 

James Robert Jones, M.B., was admitted a Fellow of 
the Society. 

The following gentlemen were declared admitted : 
— Wm. Hankes Day, M.R.C.S. (Norwich) ; Griffith 
Griffiths, M.R.C.S. (Brynedyn) ; James Hair, M.D. 
(Peterborough) ; John Fiahor Le Page, L.R.C.P. Ed, 
(Durham) ; Richard James MiUs, M.B. (Norwich) ; Alfred 
T. Roworth, M.R.C.S. (Grays, Essex) ; Charles Jamea 
Sntherland, L.R.C.P. Ed. (South Shields); Heury Thomp- 
son, M.R.C.S. (Hull), and J. A. Melville Thomson (New- 
port, Shropshire). 

On taking the Chair the President declared the Ballot 
open for one hour, and nominated Dr. James Inksoa and 
Mr. Frederick Wallace as scratineera. 





DEPBESSION OF THE FBONTAL BONE. 



Dx. OoDBtnr exlubited two in&ote, each of whom 
•howed a deep Sepremkm in the left frontal bone, the 
molt of p re mirc from the aacnl promoctorj dniing 

Od« of them, fonr dajs* old, ww delirered bj forceps 
at the City of London IMng-in Hospital by Dr. Barchell 
hi Dr. Godson's presence, and at the time of birth the 
indentation was so great that the bone appeared to hare 
been fractured, the blade of the forceps encircled the left 
malar bone and had not slipped ; the depressed bone was 
quite clear of it. The peine of the mother was mnoh 
deformed. 

The otbcT infant was delivered seven weeks ago by 
forccpK. The mother, who wa.s present, would be at once 
rocogDJsod aa rickety. The sacrnm presented a sharp 
angle. This was her fonrth child. The previoas labonr 
had been induced on accoant of the severity of the others. 

Dr. Godson had brought the cases forward on accoant 
of the identity of the locality of the depressions. It 
appeared to him natural that in a first presentation the 
head, in endeavouring to rotate into the antero-posterior 
diameter, should receive the pressure on the left frontal 
bono when the sacrum was unduly prominent, and it was 
well known how by such pressure not infrequently flexion 
was provonted, and a face presentation was the result. 
HimI flexion taken place before the head stuck and was 
■ubjertod to great pressure, the indentation would pro- 
bably have been on the left parietal bone, and this would, 
perhaps, account for the diversity of opinion as to the 
most common situation of these furrows and fractures. 

Dr. WiLTiBiKB has awn several such cases ; mostly they had 
occTirred in connection with rickety pelves, the aacral promon- 
ttiry jutting out and indenting the fcetal bead. Such depres- 
aiouB, as shown iu Dr. Oodson'a firat case, were not caused by 
forceps. CJenerally the depression did not persist, B,nd it could 



I 



UODIFICATION OP HODQE S I>E9SA.BI. 33 

■ometjmes be removed by atmospheric exhauatiou. He liad 
seen coQTulsions produced by deep depressions. Similar pits in 
the soft skull of the iiifaot might be produced traumattcally and 
disappear apoQtaneously. Dr. Wiltshire gave an instance which 
bad occurred itt St. Mary's. He had only seen such depressions 
in total skulls produced during parturition in association with 
deformity of the maternal pelris. 

Or FANconsT BAitNBa said that, in counectiou with the 
injuries whiuh the forceps was sometimes credited with in such 
cases, it might be of interest to state that he had lately seen a 
child bora with just such a furrow as was seen ou one of the 
children shown by Dr. Godsou, although instruments had not 
been used. In tbia case he had been sent for by one of the 
midwives of the Boyal Maternity Charity to a]>ply the forceps, 
but the child was born before he arrived to do so. There was 
in this caae a projection of the aaeral promontory. 

I>r. Cakteb said a few months ago he assisted at the delivery 
«f a lady who had u. contiucted pelvis, the conjugate being 
narrowed. The left parietal bone of the child was deeply in- 
dented, sufficiently so as to put into the depression the bowl of a 
desaert spoon. The forcepa were Dot put on till the head was 
in the j>elvic cavity, the labour having gone on for some hours, 
so that the depression in thia case was caused by uterine action 
alone forcing the head past the promontory of the sacrum. The 
child did well, had no symptoms of proaaure upon the braiu, and 
in about three weeks time the boue had almost recovered its 
normal contour. 

Dr. GloDaoM, in reply, said that after the birth of the child 
Si'st shown he reapplied the forceps over the mark left by it, in 
order to demostrate the impossibility of the depreaaion having 
been caused by it. He was perfectly certain that the instrument 
was no factor in its causation. 



MODIFICATION OF HODGE'S PESSAiiY. 



Dr. Gkrvis exhibited a modi&cation of Hodge'a pessary 

in which the sacral end instead of being as usual rounded 

presented a considerable central depression. The adraa- 

i tagee claimed for tliis were that the tendency of the 

I ftmdas to roU to ode aide of the pesa&ry w&s obviated ; 

vol.. zziii. 8 



34 Bxxa&-0TssiKi: PKBaNiNCY, 




that a mnch steadier pressure on the fundus was thus 
mamtaiued, and any shifting of the pessary prevented. 
The makers were Messrs Walters, Palace Road. 

Dr. Barnes aaid that tho pessaries aold as hie were not of the 
form in which he usod them. They were made of Eexible metal, 
and he moidded them himself according to the conditions of 
each patient. It waa not only neceaeary to have the upper or 
uterine end flatter and wider, but it was CBsential to provide a 
proper pelvic or vaginal curve. He thought the square shape of 
the inferior end of Br. Qervis's pessary objectionable. 



EXTRA.UTEEINE PEEGNANCT. 



Dr, Bubtom showed a specimen. It occurred in a 
married woman, set. 31, mother of five children, the 
youngest of whom was soven months old, still suckling. 
The menses had been on from the 1 7fch to the 22nd of 
January. Ou the 24th, during coitus, she slipped and 
fellj and immediately experienced a sharp pain at the lower 



^H purt of the abdomen, about two inches from the moBial 

^H line. She became faint, vomited twice, and liad several 

^^a actions of the bowels. Od seeing the patient five hoarB 

^H and a half after the injury Dr. Burton found her in bed 

^H complaining of severe pain in the spot previously described, 

^1 the position limited and well defined could in fact bo 

^H covered by the tip of the forefinger. The vomiting had 

^B ceaaed, pnlso scarcely perceptible at the wriafc, countenance 

anxious, extremities very cold, thirst intense. She 

expressed herself as feeling certain that she was dying, 

and was evidently sinking rapidly from internal hEemor- 

rhage. The only position in which any amount of relief 

could be obtained was by lying on the stomacli. Brandy, 

ammonia, ice, &c., were administered, and warmth applied 

to the extremities, but she continued to sink, and died 

nine hours after the injury. 

»A post-mortem examination was made eighteen hours 
after death ; the body was well nourished and the organs 
generally healthy. On opening the abdomen a large clot of 
blood was found filling the pelvic cavity and extending 
. some distance upwards towards the umbilicus. In all, 
between four and five pints of very dark blood were 

B removed. On examining the uterus and its appendages, 
the right Fallopian tube, about an inch from the uterus, 
was expanded into a cyst about the size of a Barcelona 
nut, in the upper surface of which was an opening big 
enough to admit an ordinary probe. This cyst has been 
cut open and will be seen to contain a fcetuB of about six 
weeks gestation. The umbilical vesicle is distinctly seen. 
The left ovary contains a corpus luteum of about quarter 
of an inch in diameter ; the right ovary on section differs 
in appearance from the other. It is mottled with 
brownish streaks, and does not to the naked eye show any 
ovisacs. The uterus is large, measuring three inches and 
^H R quarter in length, its canal moasaring two inches and 
^^■' three-quarters, of which the cervix occupies one inch 
^B and a quarter. The cavity is lined by a smooth decidua 
^H five sixteenths of an inch in thickness. The cervix has 



So BXTBA-CTBRIMB PKEONAMC?. 

evidently been lacerated in former coDfinementB, and its 
canal seems rather larger than nsnal. 

The practical point of course is, conld anything have 
been done to save the poor woman's life. The woman 
was still suckling, she had only two days before finished 
her menstrual period. She had not had a single sym- 
ptom to indicate pregnancy (and she had in the previous 
pregnancies suffered severely during the earlier months), 
yet by a negative process of reasoning I was driven to the 
conclusion that this was a case of ruptured Fallopian tube. 
Had I been called to see her, say two hours earlier, I should 
certainly have advised gastrotomy as affordiug the only 
chance of saving her life. The history of the case, the 
sudden pain, limited to one fixed spot, the condition of the 
woman, all pointed to the sudden bursting of a blood- 
vessel which could have been none other than one con- 
nected with the Fallopian tube ; but the length of time 
that had been allowed to elapse, the enormous loss of 
blood that had evidently taken place, the prostrate and 
almost pulseless state of the patient, deterred me from ■ 
attempting any operative interference. 

Dr. WiLTSHiKE said this was anotlwr and an emphatic illus- 
tration of the importance of carrying out where feasible, a, 
practice he had already repeatedly recommended in such cases, 
viz. the ligature and removal of the burst Fallopiaa tube. Had 
Dr. Burton seen tbc case earlier be might have had the privilege 
of rescuing his patient from the Jawa of death for he had accu- 
rately diagnosed the lesion. Dr. Wiltshire, while admittingtbe 
difficulties with which these grave cases were surrounded, thought 
it would some day be practised to the saving of the patient and 
credit of the profession. 






WTETBrCAl- TRANSACTIONS VOLXXIIfM 


^ 


^ 




7^ 



CASE OP VILLOUS DEGENERATION OF THE 
ENDOMETRIUM. 



By D. C. MacCaimu, M.D., M.R.O.S. Eso. 

FB0FE3SOB OF MICTCIFEBI Un> UlSBAaEB OS WOUEN INS C&ILDBBH T 



I 



Mr8. H — , set. olj waa admitted into the Montreal 
General Hospital, October 4th, 1879, for metrorrhagia. 
She has been married thrice, but hau never bom a living 
child. She beoame pregnant about twenty years ago, and 
aborted at the fifth month. Her mother suffered from 
melanotic cancer of the eye, and after removal of the 
organ the disease reappeared in the orbit and terminated 
fatally. No other case of malignant disease, so far as she 
knows, has occurred in her family. Her menses always 
observed the regular period, but the flow was scanty, 
seldom continuing longer than two days, and was accom- 
panied by pain. After the menopause, which occurred at 
the age of forty-tive, she suffered from a leucorrhcDal 
discharge which persisted for several years. Throe years 
ago she noticed a bloody diiicharge from the vagina which 
she believed to be a return of her menses. This discharge 
recurred at short intervals, and at length became so profuse 
that she applied to a physician tor relief. Not having 
received any decided benefit from the treatment adopted 
she entered the hospital. 

On examination the v^ina was found healthy. The 
uterus was in normal position but leas movable than 
usual, and it was somewhat enlarged, the uterine sound 
passing to the depth of tiiree inchef.. The introduction 
of the sound gave riae to considerable pain and was followed 
by moderate bleeding. Hhe remained in the hospital from 
October 4th, 1879, till January 8th, ls80. During this 
time she had several attacks of profuse hBemorrhage, and 
the intervals between them there was a free discharge 
from the vagina of a greyish colour, which became very 



88 TILMCS DIOBNEBATION OP THE KNDOHBTBIUH, 

ofEenaive in the month of December and continned so 
until her deotli. She Buffered also from severe pain in 
the thighs, and afterwards in the hypogaetrium. This 
pain was not constant but periodic. It came on at mid- 
night and continued for about twelve hours, after which 
it censed, and during the interval she was perfectly free 
from pain. Having obtained some measure of relief from 
thu pain, and the htemorrhage becoming less frequent and 
less profuse, she left the hospital on January 8th, but was 
readmitted on May 13th, 1880. 

Una emaciated considerably and has now a eallow 
cachectic appearance. Her countenance is expressive of 
anxiety, and she is very irritable and fault-finding. The 
disohai-go from the vagina is sanguineous and very offensive. 
The pain is still periodic, coming on daily at 10 p.m. and 
lasting till C a.m. on the following day, there being complete 
immunity from pain during the interval. By conjoined 
m&niptilation and the introduction of the uterine sound the 
utei-us ia found to have increased in size since she was first 
oxKmiued. The anterior lip of the os uteri is firm, smooth, 
rounded -and prominent, giving the impression of a small 
fibroid iu Uie anterior wall of the cervix. The posterior 
lip is thin and expanded over the enlai^d anterior lip. 

A Ur;ge sised laminaria tent was introduced and allowed 
to ntDUQ for twenty-four hours. This dilated the cervix 
Buffioiently to admit the fiuger as far as the second joint. 
~ 1 soft, inegular projections from the endometrimn 

1 be fslt. No further examination or interference was 
I fco, as A slight cut in the forefinger of my 
right hmd h*<riag been poisoned by the discharge, severe 
inflHunuttion followed, which was a long time in subsiding. 
On JoBO 9th » pledget of four laminaria tents was intro* 
dnMd. This ojpoMid op the aterns perfectly. The 
r Up being MiBod with a vulsellam and the uterus 
', the oevity wes folly explored with the finger. 
T%» whole earfeoe of the endometrinm waa felt oorered 
■nink ngeleticiiw, is pheeo moro closely ei>d thiddy 
gfonped thw in othen, and fonaing di^iDct ead 



I 

I 

I 



VILtOOS DBQEKEEiTION OP THE BNDOMETKHJM. 39 

jecting masBes. These pro]'ectionB were most marked at 
the fundus. The masses were irregular and soft, and 
portions could be detached by the finger. The sharp 
curette was introduced and the interior of the ntema 
thoroughly scraped. More than a tablespo^nfol of the 
growths was removed. They were soft and of a greyish 
colour. Their reipoval was followed by a smart haemor- 
rhage which ceased on the cavity being swabhed by 
fuming nitric acid. Portions of the growths were sent to 
Dr. Osier, Profeasor of Physiology, McGill University, 
for examination with the microscope. Ho reports as 
follows : — " The specimens submitted consisted of small, 
irregalor, greyish-looking masses, blood stained and mixed 
with small clots. Teased specimens showed the tissue to 
be made up of two chief elements, (I) cells, epithelial in 
character, the majority of the columnar type, non-ciliated, 
bnt resembling somewhat the epithelium of the mucous 
membrane of the uterus; (2) a fibrous stroma made up of 
irregular spindle-shaped cells, uaually compressed together, 
but isolated ones were not uncommon in tho field. Un- 
fortunately, sections were not made of the growth, and 
the relations of the cells to tho stroma were not ascertained. 
I was struck with tho character of the growth, and remarked 
to the member of my histology class who brought the 
specimen to me, on the difficulty of determining its precise 
nature." 

Subsequent to the scraping of the interior of the 
womb and the application of nitric acid, there was no 
return of bleeding, but .a pinkish and highly offensive 
discharge continued to flow from the vagina, and the pain 
was not relieved. The discharge becoming gradually 
more profuse and her general health rapidly and seriously 
impaired, it was decided to again dilate the uterus suffi- 
ciently to permit the introduction of the curette and the 
removal of any newly formed growths from the surface of 
the endometrium that might be detected. A small sized 
Lawson Tait dilator was introduced at noon on July 16th, 
and a second size six hours later. After removal of the 









T -' -11 aauMBnum. 


^r 


oioLibi JM <ntbe 


^^ 


-ixi made twentyjionr 


^^H 


'la niucb waeteiL On 


^H tllr . 


.= rwMt ubBBTved to be 


^^1 


--■-nuQ. It wftB 


^^H 


■»vrK adhesions 


^^H 


i-TM.'e of recent 


^H frov 


. It saittll intestme 


^H th- 


t id adhesions. On 


^H 


!<■ wails were found 


^^H 


..!ij( isrjt* eDoogh to hold a 


^^H 


.uiwi purtiou of the wall of 


^^M 


-_^ l»if ^ tba organ was about 


^^H 


^c portivii. This corre- 


^^1 


. .i!ii?rwr, rather larger 


^H 


:iaouj«*num, with the 


^V In. 


■ ,w. cvv*red with soft 


^V 


-:W ivloor, grouped 


^H 


,..-ily broken down with 




-vxHiii :rvm the proper tissue 




HI liieeaeed etracture did not 




■ >v«a«'d. The villositiea were 




' V ' liicj* membraue ol the 


^H ''' 


. k ri WHS deeply eccliy- 




..[■vr. Its sti-ucture was 




jiuut.- liucroken. 




t diMHKM Iwtrijjg infucted other 




■, tho tttwus, and its uncertain 




j^c bhw riKxird of everj cuse 




.>i lo the profession. 




Li.««.>B5 in Gjnfflcology,' Dr. 




_-..«», and observes r— " Apart 




.l>.-*-r»fd by Ors, Laiik And 




..... .-f Dr. Duuoin's, 1 know of 




The cases of Dr. Matthews 


^^^^^^^m 


, -k-r*, were published in the 




■- 



VILLOUS DKOEHEBJLTION OP IHB BNDOMETHIUU. 41 

'Obstetrical Jonmal of Great Britain and Ireland/ 

Kovember, 1873. 

Considerable doubt exiBts as to wbether tbe disease is 
to bo grouped with maliguanfc affections. In four cases, 
namely, in those of Drs. Luak and Bertelot, in one of Dr. 
Goodeil'B, and in one of Dr. Dnncan'a, tbe clinical features 
were certainly those of mabgnant disease. The remaining 
two cases of Dr. Goodell's pursued a benign course. 

In the case of Mrs. H — , taking into consideration her 
age, the bloody foetid discharge, the pain, the great irrita- ' 
bility of temper, and the marked impairment of health, 
with absence of any organic change in the cerrix: or ob 
uteri, I at first diagnosticated commencing cancer of the 
body of the womb ; but after she had been under obser- 
Tation and treatment for some time, as there was no 
marked alteration perceptible either in the size or struc- 
ture of the organ, I doubted whether my diagnosis was 
exactly correct. I therefore dilated the uterus and found 
by digital exploration the condition of villosity which is 
well represented in the accompaoyirig plate. In its pro- 
gress the disease presented clinically all the characters of 
malignancy — pain, fcetid discbarge, rapid emaciation, and 
prononnced cachexia. The death of the patient was no 
doubt accelerated by the effects of the last dilatation ; but 
latterly the degradation of health had been ao rapid that 
the strength had failed so signally, that she must have 
succumbed to the disease within a short time. 

It is greatly to be regretted that, in consequence of 
the nterus having been accidentally thrown away, the 
opportunity was lost of making a thorough microscopical 
examination of the structure of the diseased macosa, and 
its relation to the walls of the organ. 

The association iu this case of ulceration with Tillona 

degeneration, supports the view expressed by Dr. Duncan 

in his clinical lecture on " Cancer of the Body of the 

Uterus" namely, that "ulceration seems often to follow 

^M a previous condition of villosity.^' 

^H Pr. Galabik said that it wai unfortunate that the precise 



I 
I 



42 



BBPOBT OF THE HOH, LIBKABIAK. 



structure of the diseased tUaue bad cot been made out by exa- 
mination o£ sections. It was (jlear, from th^ course of the case, 
that it was clinicallj one of cancer, whatever its histological 
character might be, Euid wSiS therefore to be separated from the 
non-malignant form of ylUoub degeneration of the endometrium. 
Since, in a t«ased out specimen, it was found that beside the 
fibrous stroma there were cells epithelial iu character, and chiefly 
of the columnar type, there could hardly be a danbt that the 
disease was the so-called " cylinder epithelioma," commencing by 
the proliferation and degeneration of the uterine glanda. In 
' severol cases he had foand thi^ condition to be uniformly dis- 
tributed over the mucous membrane of the body of the uterus, so 
that at first sight it might appear to be non-malignant. One 
specimen, shown a year ago by Dr. Hoywood Smith, and 
reported oa by Dr. J. Williams and himself as a case of cylinder 
epithelioma, had been considered by other pathologists to show 
merely hypertrophy of glands. Since the disease was for some time 
confined to the body of the utema without reaching the eitornal 
surface, it would probably afford a better chance than cancer of 
the cerrix for eradioatiooB bj total extirpation of the af«rus. 



Ankdal Meeting. 

The Report of the Treasurer, Dr. GerviB, with the audited 
balance sheet, was then read. 

Moved by Dr. Champnbyb, seconded by Dr. Potter, 
and carried unanimously, " That the auditors' report be 
received and adopted." 

The Report of the Librarian was then read, and its 
adoption was moved by Dr. Wiltshibh, seconded by Dr. 
Dalt, and carried unanimoasty . 



Report of the Honorary Librarian, 



In presenting to the Society the Report which it is 
usual for the Honorary Librarian to make, I have only to 



u 



EIAHINATION OP IRDWIVZS, 



state that the Library has been, daring the j'ear, . 
tued by the Fellows of the Society, and as efficiently and 
H8 courteously managed by our excellent Librarian, Mr. 
T. WatBoii, as heretofore ; and that the Library Com- 
mittee have endeavoured, by recommending to the Council 
the purchase of each new work of importance that has 
appeared (and has not been presented to the Society), to 
make the Block of books continue to adequately represent 
obstetrio literature. 

At the boginning of the year 1880 the Library con- 
tained 3796 volumoa. Daring the year, 37 books and 45 
pamphlets have been presented to the Library, 33 books 
and 31 pamphlets have been purchased, and the periodical 
publications taken in are 46 in number ; so that in all, 
123 volumes have been added to the Library, which now 
contains 2919 books. 

A catalogue of tho Library, classified according to sub- 
ject, the works on each subject arranged in chronological 
order, will, it is hoped, be shortly in the hands of the 
Fellows of the Society. 

G, Ernkst Herman. 

Tho Report of the Board for Examination of Midwives 
was then road, and its reception and a vote of thanks to 
tho Chairman, Dr. Aveling, was proposed by Dr. Godsom, 
seconded by Dr. Galabih, and was carried with applause. 



The Ezamivalion of Midwives, 

Tho Board established by the Society for the examina> 
tion of midwives has had a larger number of candidates 
to examine than upon any previous year. The number 
of appbcants last year was twelve, this year there have 
boon twenty-four women seeking the diploma of tho 
Society. This increase in the number of candidates is 
probably in a great measure due to the new rule, which 
tMiablits (Hxintry women to undergo their written examina- 



OfFlCKBS AND COUNCIL. 45 

tions nearer home, each Local Secretary being now em- 
powered to superinteDd these examinations in the town 
for which he holds his appointment. 

Although the Board observes this increase in nambers 
with great satisfaction, it still continues to feel bow 
inadequate the efforts of the Society are in providing a 
public test for skilled niidwives j and it begs respectfully 
to point out to the Council the necessity there is for 
further exertion to induce the Government to recognise 
the importance of ameliorating the present condition of 
tnid wives. 

The Board has reason to believe that the Lord President 
would, at the present time, receive .with favour a deputa- 
tion from this Society, urging the importance of securing 
ior the public safety a body of competent midwives. 
J. H, AVELING, M.D., 



The Scrutineers retired, and on their return the result 
of the ballot for ofiicers and council for the ensuing year, 
was declared as follows : 

Honorary President. — Arthur Farre, M.D., P.R.S, 

Prendent. — J. Matthews Duncan, M.D., F.R.S. Edin. 

Viet-PrceidenU. — John Baasott, M.D. (Birmiugham) ; 
Jonathan Hutchinson, F.li.C.S. ; John Baptiste Potter, 
M.D. ; George Roper, M.D. ; Jolrn Thorbnm, M.D. (Man- 
chester) ; John Williams, M.D. 

Treasurer. — Henry Gervis, M.D. 

Hotiorarif Secreta/ries. — Clemeat Godson, M.D. j Alfred 
Lewis Oalabin, M.A., M.D, 

iltriiorary Librurimt.—Goorge Ernest Herman, M.B. 

Other Memhera of Council. — James Andrews, M.D. 

S. Fancourt Barnes, M.D. ; Henry Bcnnet, M.D. 

(Weybridge) ; Charles Heury Carter, M.D. ; FranciB 

Henry Chompneys, M.A., M.B. ; Richard Cross, M.D. 

(Scorboroogb) ; Robert Cory, M.B. ; Edward Maiuig^ 



M.D. (Binningliam} ; George Rice Ord ; Richard King 
Peirce ; David Lloyd Roberta, M.D. (Manchester} ; 
Frederick William Salzmann (Brighton) ; Charles Brodie 
Sewell,M,D. ; William Daniel Slyman ; William Stephen- 
son, M-D, (Aberdeen); George Dancer Thane, M.D; 
Frederieb Wallace; George Engene Yarrow, M.D. 

The President then delivered his annual address. 

ANNUAL ADDRESS. 



Gentlemen, — It is again my pleasing duty to congratu- 
late the Society on its continuous prosperity. Since onr 
last annual meeting we have elected forty new Fellows, 
while we have lost thirty-seven by death and resignation. 
The Society now numbers 749 Fellows. 

Outside the special worfc of the Society there are two 
matters worthy of your notice, since they have to do with 
the general progress of the department of medical science 
in which we are specially interested. 

One of these is the representation of obstetrics on 
the General Medical Council. The attention of the 
profession has more than once been called to the strange 
fact that in what is practically the parliament of our 
profession, which undoubtedly ought therefore to rep- 
resent all branches of medical practice equally, there has 
hitherto not been a single member who practised obstet- 
rics, and who might claim to speak with authority 
when subjects connected with it were discussed. The 
result of this glaring defect has been that obstetrical 
questions have been very inadequately treated ; not, I am 
sure, purposely, but from a very natural ignorance of 
their merits. When we reflect that obstetrics form a large 
and important part of the daily work of an immense 
majority of the medical profession, we are surely justified 
in maintaining that there should be some members of the 
Medical Council who know something about the matters 



I 



AinnTAL ADDKISB. 47 

tbey are discasaing. During the paet year a vacancy 
occurred in the Medical Coancil by the death of Dr. 
HadsoDj and since the nomination was vested in the 
Crown, your Council empowered me to head a deputation 
to the Lord President of the Council for the purpose of 
pointing oat to him the facta I have alluded to. Unfor- 
tunately he was unable to receive us, and I therefore 
addressed to him a petition on behalf of the Council, a 
Bimilar course having been adopted by the Obstetrical 
Society of Dublin. No definite decision has yet been 
announced, but there is good reason to hope that our 
memorial will lead to the nomination of an eminent 
obstetrician, whose name is of itself a sufBcient guarantee 
that the interests of obstetrics will in future be properly 
represented in the deliberations of the "General Medical 
Council. 

Another equally glaring, and even less defensible, ano- 
maly was the fact that in the examination for the mem- 
bership of the Royal College of Surgeons obstetrics had 
no place. As the membership of the College forms the 
most common of all the qualifications for general practice, 
that must be admitted to have been not only a defect, 
but an absurdity. That the College should give its 
imprimatur every year to the qualification to practise of 
hundreds of men, without the slightest attempt to satisfy 
itself that they possessed the most elementary knowledge 
of one of the moat ailxioue and responsible branches of 
their profession, may fairly be said to have been some- 
thing even worse than an absurdity. I am happy to be 
able to announce to you that this reprehensible state of 
things is about to be put an end to, the Council of the 
College having decided that oo and after the 1st of 
January, 1882, the candidates for the membership shall be 
examined in midwifery aa well aa in surgery and medicine. 

The past year has certainly been not less fertile Ihan 

its predecessors in the amount of work which the Society 

has accomplished. Not only have the meetings been well 

^L attended, but the discussions have often been lively and 



* 



48 



ANNUAL ADDBBSa. 



interesting. The oastom which the Society has adopted 
from the first of reporting at length in our ' Transactions ' 
the discussions which have followed the reading of papers 
haa always seemed to me to be a very valuable one. By 
this means the varying opinions entertained on any special 
Bubject are permanently recorded, and much interesting 
information may be gathered from them which would 
otherwise never be obtained and be entirely lost. I am 
conscious of having myself gained, from time to time, 
important knowledge from this source. 

At our first meeting we had an elaborate statistical 
record by Dr. Champneys on the site, character, and best 
mode of relieving the pain in uterine cancer. The deduc- 
tions made by him from fifty carefully observed cases 
differ somewhat from the opinions which have been 
generally entertained. In his statistics as many of the 
patients affected were between thirty and forty as between 
forty and fifty years of age. This is certainly contrary to 
general experience, and Dr. Champneys' results were 
probably to some extent accidental, in consequence of the 
comparatively small number of cases observed. Thus, for 
example, out of 108 cases carefully noted by ycanzoni, 
60 occurred between forty and fifty years of ag^ and 
only 35 between thirty and forty ; while out of 112 cases 
recorded by Emmet, 42 occurred between forty and fifty 
years, 3U only between thirty and forty. It is to be 
hoped that Dr. Champneys will extend his observations 
on this disease to other points even more important than 
that of pain. I know of few topics in connection with 
gynecology in which more promising results are likely to 
be obtained by advancing knowledge than in that of 
uterine cancer. To point to one subject in connection 
with its etiology only, the statement made by Emmet, and 
supported by Thomas in his latest edition, that all cases of 
epithelioma have their origin in laceration of the cervix, 
requires careful study ; since, if this be so, prevention is 
not altogether beyond our reach. Then, as regards 
treatment, we are already far in advance of the gyneoo- 



I 



ANMUiL ADDBESK. 49 

logists of only a few years ago in dealing with this most 
deadly disease ; and the very generally entertained opinion 
o£ pathologists of the present day as to its essentially 
local origin, strongly enconrages us to study the means at 
our disposal for eradicating it before it has made such 
ravages in the affected part as to render all interference 
useless. This subject has already engaged the attention 
of the Society in a paper by Dr. Wynn Williams on the 
local treatment of cancer by bromine. In the removal of 
epitheliomatous growths of the cervix by the knife and 
gal vano- caustic, after the plan recommended more espe- 
cially by Marion Sims, I have, from time to time, obtained 
most encouraging results, and the possibility of dealing 
with such growths much earlier and more effectually than 
has hitherto been the case should obtain our earnest 
attention. Then, again, there is the very important sub- 
ject of the total extirpation of the uterus in early stages 
of malignant disease, a question which calls for the most 
serious study, and which, strangely enough, has not been 
yet taken up in this country, the cradle though it be of 
abdominal surgery. Although the originator of the 
method. Professor Freund, of Breslau, has operated four- 
teen times with five recoveries, and his example has been 
followed by many of the leading surgeons in Germany, I 
have only heard of one or two unsuccessful operations in 
this country, and the subject has not yet been bronght 
under the notice of this or any other society. Probably 
the extreme complexity of Freund's operation may account 
tor the small degree of favour it has as yet received in 
Great Britain. No one can doubt, however, that in these 
days, in frhich uterine symptoms receive much earlier 
attention than was formerly the case, malignant disease of 
the uterus may very frequently be detected before it hau 
spread to any of the sorrounding tiasnes, in which it is 
strictly limited to the uterusj and in which that organ is 
still perfectly mobile. Perhaps there is no organ in the 
body, except possibly the mamma, in which total extirpa- 
tion promises more snccessfol results, if only a compara- 
VOL. zxiu. 4 



50 ANNDAL ADDRESS. 

tively simple operation could be devised. It is wortr^ 
note that that great obstetrician, Dr. Blundell, fully 
recognised this fact long before the days of abdominal 
surgery had commenced, and actually removed the uterus 
in four cases from the vagina, and I am by no means 
certain that some modification of the plan he adopted may 
not yot be found easier thau Freond'a operation. Aa a 
matter of fact. Professor BiUrothj of Vienna, has, during 
the past year, resorted in several cases, in some success- 
fully, to a modification of Blundell'a operation, which he 
maintains to be far more easy and satisfactory than 
Preund'fi. Be this as it may, I trust I may be pardoned 
for specially directing the attention of those of our Fel- 
lows who are experts in abdominal surgery to this topic, 
in the hope that they may, ere long, bring it nnder the 
notice of the Society. 

At the April meeting Mr. Lawson Tait read a paper, 
which may be here mentioned as it deals with an intereat- 
iug and hitherto little studied point in abdominal surgery, 
on " The Asial Rotation of Ovarian Tumours leading to 
their Death." It not only added to our knowledge of the 
accidents attending ovarian disease, but led to an important 
discussion, in which many of our prominent ovariotomists 
took part, which the Fellows doubtless remember. Mr. 
Tait's ingenious theory as to the. cause of this accident 
being the alternate filling and emptying of the rectum, 
although not generally admitted to be correct, struck me 
as very interesting. There can be no doubt that the 
presence of this viscus, and its varying dimensions in the 
pelvis, plays an important part both in obstetrics and 
gynecology, which hns not been sufiiciently studied. 
although its influence has been recognised by Sir James 
^jDpsou and other writera. I can imagine a valuable 

r being composed on tbis subject, 
I Another of the burning questions of the day in connec- 
l with abdominal surgery occupied the Society on the 
reading of a paper by Dr. Godson, recording a successful 
la)>wvtouy performed by Mr. Spencer Wells, and a very 



ANNUAL ABDBSSS. ol 



important paper by Mr. Knowaley Thornton on " The 
Removal of Uterine Fibroids by Laparotomy," and cer- 
tainly no more interesting aabjecta could come under dis- 
cussion. We had the advantage of hearing the views of 
many well qualified to speak on this point. No one can 
doubt that a great future lies before this operation, and 
the brilliant results of tlie antiseptic method, properly 
and carefully carried out, in abdominal surgery, certainly 
render the chances of success much greater than they 
otherwise would be. While I fully admit that the removal 
of uterine fibroids by hysterectomy, in properly selected 
cases, is a perfectly legitimate procedure, I cannot think, 
with some who took part in the debate, either that this 
operation can be talked of as on a level with ovariotomy, 
or that it is ever likely to become so ; and I am inclined 
to hold that this is a subject in which the brilliant suc- 
cesses of ovariotomy, and the operative skill resulting from 
them, are perhaps a little apt to warp our judgment. In dis- 
eases such as ovarian tumour, uterine cancer, and the like, 
which, if left to run their natural course, must, of neces- 
sity, ere long prove fatal, no difficnlties and no dangers 
need stand in the way of an attempt at radical cure. In 
diseases which may embitter life from suffering, but which 
probably may not kill at all, or only after many long 
years, the resort to an operation of such gravity should, I 
venture to submit, stand on an entirely different footing. 
Id some cases it is undoubtedly legitimate, and in one of 
Mr. Thornton's cases which I saw with him, I myself 
counselled the patient to undergo the operation ; but the 
momentous decision is not to be lightly made, and much 
stady of the natural progress of fibrotnas is still required 
before one can feel justified iu arriving at very positive 

L conclusions on this point. It is to be remembered, too, 
that in the cases of Sbroid in which life is most often im- 
perilled — those accompanied by profuse and exhausting 
hemorrhage — there is a fair prospect of material benefit, 
if not of complete cure, from the far leas serious and leas 
difficult operation of spaying, the indications for which, 
■hi rf* ■ 



I 



£2 

like those of laparotomy, are still suh jmUce. I have 
ventured to make theae observation s, because I fear there 
ia a tendency to resort somewhat rashly to this grave pro- 
cednre, which time and greater experience will doubtless 
modify. I am well aware that in the hands of such expe- 
rienced and careful operators aa Mr. Thornton there is no 
risk of the kind I have indicated, but I have elsewhere 
known of more than one case in which laparotomy has 
been recommended where, in my judgment, it was by no 
means imperative, and in which the tumour in no way 
imperilled the patient's life, and even interfered very little 
with her comfort. A word of caution may, I trust, there- 
fore be considered to be not altogether out of place. 

The June and July meetings were pretty fully occupied 
by a paper by Dr. Graily Hewittj on " Uterine Flexions," 
and by the discussion which followed it ; and although it 
was not a formal debate on a settled subject, such as that 
which we had last year on the " Use of the Forceps," it was 
80 animated and prolonged that it practically assumed the 
dimensions of one. I have heard it said that we have 
had somewhat too much of flexions in our Society, and 
that it was time the subject was dropped. 1 cannot 
myaeif quite endorse that view, for, doubtless in great 
measure owing to Dr. Hewitt's persistent advocacy of his 
own theory of uterine disease, the profession and the public 
have got a rooted hold of the subject; and whenever 
nterine symptoms exist, not well understood, we are now 
told that the womb is probably displaced. It is, I think, 
greatly to be regretted that in gynecological practice 
there is this tendency to run into extremes, and fix atten- 
tion too exclusively on one class of disease only, whether 
it be what is called an ulcerated womb, a displaced organ, 
or, what is likely to be the gynecological lesion o£ the 
future, if we may believe oar American brethren, a lace- 
rated cervix. This being bo, it cannot be unimportant 
that the subject should be thoroughly diacussed in all its 
bearings ; and I trust, therefore, that the time we devoted 
to it may prove to have been well spent. Personally, 



ANNUAL ADDRESS. 



53 



^L retai 



although I dare say my friend, Dr. Hewitt, may consider 
me a somewhat lukewarm follower, I owe it to him to 
state that I attach much greater importance to flexiona 
than I did some years ago, and this has followed from a 
study of his views and opinions. Indeed, I am at a loss 
to understand how any one who sees much uterine disease 
can possibly doubt the extraordinary effects produced by 
flexions, or the equally CKtraordinary results which follow 
judicioQS mechanical treatment. This is, however, a very 
different thing from admitting Dr. Hewitt's theory that 
all uterine disease is caused by flexions — a view which not 
only leads, as I venture to thiak, to mistaken practice, but 
causes those who adopt it to overlook many conditions of 
primary importance. I trust these remarks may not be 
misunderstood j but it seems to me, above all things, 
necessary in this special department of practice that we 
should hold broad views, and not let ourselves be led into 
a narrow groove, the following of which, by men less able 
than Dr. Hewitt himself, may lead to much that is strongly 
to be deprecated. In the address which I dehvered at the 
Obstetric Section of the British Medical Association at 
Cambridge in August last, I ventured to point out that 
tho reason why gynecological practice was in some res- 
pects so uncertain was the want of accurate pathological 
knowledge of the condition of the parts affected ; a want 
for which we are not altogether to blame, since it results 
partly from the comparatively short time that has elapsed 
since the diseases of women became the subject of special 
study, and partly from tho difficulties that surround the 
pathological investigation of the diseased organs. Since 
writing the above I have had the pleasnre of reading in 
the new edition of our Honorary Fellow, Dr. T. Gaillard 
Thomas's admirable work on the ' Diseases of Women,' 
some remarks which so strongly corroborate the observa- 
tions I have made on this point, that I shall venture to 
quote them. "Nothing," he says, "more decidedly 
retards the progress of gynecology, lowers it as a special 
study in the eyes of its sister departments, and fans the 



54 



ANKTTAL ADDEBBB. 



dying flame of a prejudice with which it has been BucoeBS- 
fuUy able to contend only diii-ing the past, half century, 
than tho unsettled state of uterine pathology. In general 
medicine, in surgeryj and in all othei- epecial departments, 
the study of pathology is made the keystone of the arch 
which supports them ; and observers seem willing to 
agree as to fixed principles concerning it. In gynecology 
the whole subject presents the melancholy aspect of 
nncertainty and dissension. Many of its votaries, instead 
of taking broad and strong views, become the partisans of 
some special dogma or theory, which is warmly attacked 
by others who hold some view equally narrow, incompre- 
hensive, and exclusive." Perhaps this unhappy state of 
things is not unnatural in a comparatively new study, but 
the move frankly we recognise the shortcomings of our 
department, the sooner shall we get rid of them ; and wo 
have had some excellent work before us, such as in the 
account of the " Pathological Anatomy of Erosions of tho 
Cervix Uteri," and on the "Histology of Endometritis," 
by our honorary secretary. Dr. Galabin, which shows that 
considerable attention is now being paid to this topic. 

There are many other papers of importance besides 
those I have referred to, on which, did time allow, I might 
very properly remark, but I have, I fear, already trespassed 
too long on yonr patience to justify my referring to them. 
I must, however, make a passing allusion to Dr. Priestley's 
interesting paper on "The Induction of Abortion as a 
Therapeutic Measure," since it is the first attempt, so far 
as I know, to systematise the causes which may justify the 
practitioner in resorting to this distasteful procedure, and 
lo lay down laws for his guidance. It is surely time that 
a subject such as this should bo fairly grappled with, 
and I am sure we must all agree in thinking that Dr. 
Priestley not only did us a service in bringing it before 
us, but that he has laid down a series of very judicious 
rules in regard to it, which, if strictly attended to, may 
prevent the abnse of this procedure. In other countries 
the production of criminal abortion has become, we are 



AMKDAL ADDRESS. 



55 



I 

H wel 

^M Dot 



told, almoat a system, and 13 practised with nnbluahing 
openness, leading, as it may well do, to most disastrous 
results. Fortunately for us, nothing of tlia kind exists 
here, at least, not to any appreciable extent, and I trust 
that Dr. Priestley's paper may, by the safeguards it has 
laid down, assist in preventing this moat pernicious prac- 
tice ever becoming prevalent amongst us. 

We have fewer deaths to lament amongst our Fellows 
this year than is usually the case. Amongst those of 
whom I can find no obituary record are William Henry 
Maberly, M.D., CM. Edinburgh, of 1, Mineford Gardens, 
West Kensington Park, and Alfred Walker, M.D., of Fore 
Street, Hertford. 

Dr. Thomas FaJrbank, of Windsor, died with appalling 
suddenness on the 26th of March, at the early ago of 
thirty-sis, thus prematurely bringing to a close a career 
of greai promise. Dr. Fairbank was born in ]8-t3, and 
received his education at Forrest School, where he showed 
much aptitude for classical studies. His family wished him 
to proceed to Oxford, but his strong predilection for 
medicine induced him to forego the advantages of a 
university education, and, at the age of seventeen, he 
entered at the Medical School of St. Bartholomew's 
Hospital. Hero he greatly distinguished himself, and 
proved the zeal with wliioh he had devoted himself to 
medical studies by his brilliant success at the London 
University, where he graduated in 1864, securing a first 
class in medicine, forensic, and obstetric medicine, and 
gaining gold medals in the two former subjects. Shortly 
after this Mr. Brown, Surgeon to the Queen's Household 
at Windsor, having died, Dr. Fairbank was, on the recom- ' 
mendatiou of Sir James Clarke and Sir James Paget, 
selected to fill his place in partnership with Dr. Ellison. 
Dr. Fairbank was well fitted for this responsible post, and 
secured the regard of Her Majesty and many members of 
the Boyal Family with whom he was brought in contact, as 
well as that of a large and inflncntiat private clientilc. It is 
Dot often that so young a man Ends himself placed in sncli a 



56 



AimrAL ADDRESS. 



fortunate poBition, but in this instance, the good foptnne 
was proved to have been well bestowed, and Dr. Fairbank 
was, I understand, for I bad not the pleasure of being 
personally acquainted with him, a universal favourite. 
His lamented death was due to an aneurism of an artery 
in the brain. He contributed to the ninth volume of our 
' Transactions ' a very interesting case, in which the pelvis 
was extensively fractured daring pregnancy, and in which 
a subsequent pregnancy was happily terminated. 

In Dr. Oopovian, of Norwich, the Society has lost one 
of its most valued provincial Fellows, who had acquired 
considerable eminence as an obstetrician, and one who 
evinced his interest in the Society by numerous contri- 
butions to its ' Transactions.' Dr. Copeman waa born at 
Great Withingham, in Norfolk, in the year 1809. He 
commenced his medical career as a pupil, first of Mr. 
Brown, of Norwich, and subsequently of Mr. Crosse, the 
well-known surgeon of that city. He next studied at St. 
George's Hospital, becoming a Licentiate of the Society 
of Apothecaries in 1S32, and a Member of the Royal 
College of Surgeons in 1833. He then served for some 
time as house surgeon to the Norfolk and Norwich 
Hospital, subsequently entering into general practice at 
Cottishall in Norfolk in partnership with the late Mr. W. 
Taylor. Here he obtained a large practice, but the 
sphere was too limited for his energies, and in the year 
1848 he removed to Norwich, and established himself as 
a consulting physician, having previously obtained the 
Fellowship of the College of Surgeons by examination, and 
the M.D. of Aberdeen. He also became a Member, and 
was eventually elected a Fellow, of the Royal College of 
Physicians. Dr. Copeman's contributions to Medical 
Science were numerous and important, and he was peculiar 
in being one of the very few provincial physicians who 
specially cultivated, and greatly distinguished himself in 
the obstetric branch of medicine. His first work was on 
apoplexy, in which he was one of the first to object to 
the routine practice of indiecriminate bloodletting then in 



ANNUAL ADDRESS. 57 

vogue ; and it ia interesting, as an evidence of his fairness 
and impartiality, that one of his last papers, published in 
the ' British Medical Journal ' in 1879, was a contribution 
on venesection in which he maintained that the reaction 
against that remedy had been carried too far, and 
instanced several conditions in which it might be usefally 
employed. It is, however, in Dr. Copeman's obstetric 
work that we are specially interested. His contributions 
to this branch of the pi-ofesaion are varied and numerousj 
and prove the great interest which he took in it. Among 
the most important may be mentioned several papers and 
monographs on puerperal fever, written chiefly with the 
view of impressing on the profession the value of 
turpentine in the treatment of this disease. In perusing 
these I have been struck with Dr. Copeman's clear appre- 
ciation of the nature of this scourge of midwifery prac- 
tice, which seems to me to have been beyond the knowledge 
of the time at which he wrote, his first paper having been 
published in 185(3, He then not only absolutely discards 
venesection in its treatment, but much more fully realises 
its adynamic nature than most writers at that time would 
have done. He also very distinctly states his belief that 
many cases were probably produced by the absorption of 
septic matter from putrid lochia, portions of retained 
membrane, and the like, and recommends as an essential 
part of the treatment the frequent and regular washing 
out of the vagina with copious injections of warm water, 
thus foreshadowing points in the etiology and treatment 
of puerperal septicaemia, the importance of which are now 
fully recognised, but which, at the time he wrote, had 
received little or no attention from the profession. 
Amongst other monographs he wrote may be mentioned 
one of considerable value, " On the Cerebral Affections of 
Infancy,'' which contains much interesting information. 
The work by which Copeman, however, will probably be 
best remembered is his suggestion for the relief of the 
vomiting of pregnancy by dilatation of the cervix uteri. 
There is something which seems to have taken the pro- 



58 



ABNCAI. ADDBESa. 



fession in this proposal, since much has been written upon 
it; and Dr. Copeman himself evidently believed that ho 
had made in this a very valuable discovery. My own 
experience of it is too slight to justify my speaking of its 
merits with much confidence, nor can I say that in the 
cases I have tried it, I have found it answer the expecta- 
tions of its originator, who obviously looked upon it as a 
specific in the treatment of the vomiting of pregnancy. 
What, however, has surprised me in reading both 
Copeman's papers, and those of others who have written 
upon the subject, is that no one seems to have been struck 
with the obvious danger attending it of inducing abortion. 
To me it seems evident that the rough and frequent 
dilatation of the cervix is a measure which may certainly 
do much to relieve sickness by putting an end to the 
pregnancy altogether, and, therefore, when practised, it 
should be in a very cautions and tentative manner. Dr. 
Copeman was also a frequent contributor to our 'Tran- 
sactions,' imongst his papers may be mentioned those on 
"Labour complicated by Pelvic Tumours," on "The 
Value of the Placental Souffle as a sign of Pregnancy," 
besides several others of considerable interest. 

In private Dr. Copeman was respected and beloved by 
all who knew him. Like many men of distinction be did 
not limit his energies to his profession, but took an active 
pari in much in connection with the city in which he 
lived, that was beyond the range of his professional work. 
Thus, being an enthusiastic and accomplished musician, he 
served for many years as the Chairman of the Committee 
of Management of the well-known Norwich Musical 
Festivals. He died on the 23rd of February fi-om a 
sudden attack of cardiac dyspncea, having been engaged 
in active work to the last. '* Dr. Copeman," says a Norwich 
paper, in an obituary notice, " was not only an accom- 
plished physician, but he was distinguished by great 
ability, combined with high and generous impulses. He 
was a warm friend, and, in every sense of the word, a 
Christian gentleman. By his death medical science has 



I 



ANKUAL ASDHRES. 99 

been deprived of one of its moat active votaries, and 
Norwich has lost one of her foremost citizens." Higher 
praise than this none of us need nspire to, 

Henry Charles Baieman, F.S.O.S., who died on the 
21at of November, at latington, where he had practised 
for upwards of fifty years, was probably well known to 
many now present. 

He was born in 18u6 at Barton- on-Trent, and waa 
educated at the Burton Grammar School. He received 
hia medical education at St. Bartholomew's Hospital, 
where he was a fellow student of Owen, and a pupil of 
Aberaethy, After completing his studies at Paris he 
settled in Islington in 1830, and was appointed surgeon 
to the Islington Dispensary. From that time to the end 
of his career, his life was one of unceasing work, much 
of it spontaneous and unpaid, such as few, even if their 
health permit, have the energy to undertake. Ho soon 
began to see patients gratuitously, and for eight years 
did so every day from before 6 until 9 p.m., and con- 
tinued hia practice three days a week up to the end of 
his life. It must, I fear, be admitted that such indis- 
criminate and exhausting self-imposed labour, although 
doubtless undertaken from the best motives, must neces- 
sarily have led to abuse. In addition to this Mr. Bateman 
gave much work to promoting the interests of the Sweden- 
borgian community, of which ho was a zealous supporter, 
and used to preach a sermon every Sunday. His death 
removes from the ranks of the profession a man in many 
respects remarkable, who for many years had carried on 
one of the largest obstetric practices in the Metropolis. 

Amongst oar Honorary Fellows we have to lament the 
loss of Profcgnor Francesco Rizzoli, of Bologna, who died 
early in the year in that city. Rizzoli was comparatively 
little known in this country, yet he was a man of indo- 
mitable energy, profound scientific acquirements, and 
universally beloved and respected by his companions. 
Rizzoli was bom in Milan id the year 18U9, his fatjier 
having been assassinated by brigands shortly before big 



60 ANNUAL ADDBESS. 

birth. Adopted by an uncle, he was educated at Bologna. 
After having completed his medical education at the 
University of Bologna, he was appointed assistant sur- 
geon to the Hospital of the Abbandonati in that city, 
and in the year 1836 was made Assistant Profesaor of 
Surgery and Obstetrics, and in 1842 succeeded to the 
Chair when Professor Baroni removed to Rome, on being 
appointed medical attendant to Pope Gregory XVI. 
This appointment he held until 1865, when he became 
Emeritus Professor and consulting surgeon to the hospital. 
Rizzoli's life was one of unceasing labour. Besides a 
large number of unpublished monographs, which are 
shortly to be printed, he had published a voluminous and 
very valuable collection of papers on various subjects con- 
nected with surgery and obstetrics, which have run through 
several editions. This coutains twenty-seven papers on 
surgical subjects, and eight on obstetrics. The latter 
are chiefly on points connected with obstetric operations, 
but one is on snperfoetation and missed labour. It is 
specially interesting, as it embodies observations on these 
subjects which have recently been published in this 
country as new, and records many very interesting eases. 
Eizzoli was an ardent patriot, and signalled himself by 
his zealona endeavours to secure the unity of Italy. Some 
years before his deatli his public services were recognised 
by his being appointed a senator by Victor Emmannel. 
Eizzoli bequeathed the whole of his fortune for the 
purpose of establishing a. new hospital in Bologna, which 
is now in the process of construction. 

And, now, Gentlemen, it only remains for mej in 
resigning the honorable position which, through your 
favour, I have held for two years, to renew to you my 
thanks for the confidence you placed in me by electing 
me to be your President. From the Council, and from 
every oiRce bearer of this Society, more especially from 
our energetic and able Honorary Secretaries, I have 
had such zealous assistance, that the work I have bad to 
do has been almost nil, and to each and all of them I 




MUAL ADDBESS. 



61 



I 
I 



owe my hearty acknowledgmenta. To the end of my life I 
shall regai'd my occupancy of this chair as a most signal 
honour, and having the interests of the Society much at 
heart, I sincerely congratulate it on the prospects of 
being presided over by the distinguished obstetrician who 
is to succeed mej under whose leadership it cannot fail 
to flourish in the future, as it has hitherto done in the 
post. 

Dr. Priestley said, in proposing the resolution which 
had been put into his hands, that he would with the permis- 
sion of the President, and the concurrence of the Fellows, 
adopt the somewhat exceptional course of addressing 
himself directly to the Society rather than to the chair. 
He had great pleasure in moving a vote of thanks to the 
President for his excellent address just delivered, aud 
for his conduct in the chair daring his term of office. 
The Society had heard his admirable and lucid resume 
of the chief events of the session, and it was gratifying 
to leum that during his occupancy of the chair, the Society 
bad still continued to prosper. There had been no falling 
off in the number of Fellows, and the contributions and 
discussions bad maintained tho interest of former years. 
Fortunately, the President of the Obstetrical Society had 
not been embarrassed in coad noting debates by the 
difficulties encountered by the Speaker and Deputy 
Speaker in another place, but he (Dr. Priestley) had 
had some experiencu in presiding over the discussions of 
the Society, and ho knew quite well that it was not 
easy in regulating the proceedings to give satisfaction to 
all. He believed, however, that the Fellows would 
concur with him in thinking that Dr. Fl&yfair had dis- 
charged his functions with conspicuous fairness, combined 
both with courtesy and urbanity. He was sure Dr. Play- 
fair, in vacating the presidential chair, would carry with 
him the good wishes of the entire Society, and in retiring 
he would have the satisfaction of knowing that he would 
succeeded by one who had attained more than a 



6i AHNDAL ADDKESB. 

European reputation, and who would be fnlly c&pable of 

maintaining tLe dignity of the chair. 

The resolution he moved in formal terms was, " That the 
best thanks of the Society "be given to the retiring Presi- 
dent, Dr. William Playfair, for the efficient manner in 
which he has presided over the meetings of the Society 
during his term of office, and that he be requested to 
allow his interesting address to be printed in the next 
volume of the ' Transactions.' " This was seconded by Dr. 
Gervis and carried by acclamation. 



A vote of thanks was also moved to the retiring Vice- 
Presidents and other members of Council by Dr. Bruwton, 
seconded by Dr. Pbuct Boulton, and carried unanimously. 



J. Matthews Dcncam, M.D., F.R.S. Ed., President, iu the 
Chair. 

Present — 62 Fellows and 11 visitors. 

Books were presented by Mr. A. Doran, Dr. G. B. 
Ercolani, Dr. A. L. Galabin, Dr. George Hoggau, Prof. 
Alois Valenta, and St. Bartholomew's Hospital. 

Kanaheiro Takaki.F.R.C.S. (Tokio, Japan), was declared 
admitted a Fellow of the Society ; and George Albert 
Farrer, M.R.C.S. (Brighouse, Yorkshire), and William 
Gandy, M.R.C.S. (Gipsy Hill), were elected Fellows. 



INTERSTITIAL FIBROID CAUSING RETRO- 
FLEXION. 



Dk. God sou showed for Dr. Dewar a specimen of 
interBtitial fibroid, and read his notes of the case, as 
follows : 

" Mrs. P — , EBt. 43, widow, sterile. Three years ago I 
attended patient who was then suffering from pain in the 
back, Ac, due to retroflexion of the uterns. A Hodge 
pessary was introdaced, which she wore with advantage 
for some time ; then it began to give her pain and had to 
be removed. 

" About a year after this she was seized with an acute 



64 INADSnBAL ADDBBfiS. 

attack of pelvic peritonitis which lasted six weeks, aad 
left the uterus fixed and surrounded with plastic effusion. 
Iodine externally and locally was used but patient left off 
attending. Since that time has frequently complained of 
pain in the left side ; bat she was of a highly nervous 
temperament. 

" Last Sunday evening was requested to see patient, and 
I found that for moat of that day she had been suffering 
from severe vomiting and diarrhma, with considerable 
pain and tenderness all over the abdomen ; also a good 
deal of pain in the back. She complained of feeling 
cold. Pulse 120 and thready, temp. 101°. Although 
opiates soon relieved the sickness and diarrhcea, she died 
rather suddenly towards the morning, 

" I was allowed to open the abdomen. Found peritoneum 
adhering in several places, and the whole of the intestines 
injected. No effusion. Per vaginam uterus was found 
to be rctroflected as it was three years before, but quite 
movable, and no hardness suiTounding it. Right ovary 
quite free, but the left was adherent to the bowel, &o., 
and could not be separated. Uterine canal three inches 
and a half in depth. 

" The specimen shows a small interstitial Gbroid situated 
on the anterior wall of the body of the uterus. The 
fundus was pointing downwards very markedly, which 
position it retained for some time after its removal from 
the body. She never had metrorrhagia." 

The Presidknt {Dr. J. Matthews Duncan), then de- 
livered his Inaugural Address. 



INAtrGUEAL ADDRESS. 



I HAVE great pleasure in thanking yon for the very 
high honour you have conferred upon me by placing me 
in this chair, a position which has acquired biennial 



1 



65 



increinenta of eminence from the well-deserved renown of 
the great physicians who have Buccesaively occupied it, and 
not least from that of oar last president, Dr. Playfair, the 
anthor of valuable laborions monographs and of tv popular 
text-bookj an esteemed teacher, and a famous practitioner. 
We are grateful to him for tho time and labour he has 
given UB, and I can only hope to imitate him in these 
respects as well as in his urbanity and gentleness. 

The beat honours in medicine are conferred by profess- 
ional brethren, our peers, who alone are competent judges, 
who alone, indeed, know us. But I dare not rate my present 
position without deeply feeling that, proportionate to tho 
honour, nre the responsibilities and the duties. To take 
my allotted share in tho mero business of this great and 
prosperous Society is not a heavy undertaking, but the 
other and less prominent duties of ray position are really 
onerous — to preside, to direct, to encourage, to repress ; to 
do all this in tho proper spirit and in a manner that cannot 
be misinterpreted. I shall try, in reliance on your gene- 
rosity and kindness, and support, to keep unbroken the 
good reputation, as a Society, which wc have hitherto 
maintained. 

This Association has been, and continues to be, pros- 
perous. Its membership ia very numerous, its exchequer 
well replenished, its meetings well attended ; above all, its 
proceedings are interesting, and its annual volume of 
' Transactions ' replete with vuluable matter. 

In the proceedings of our ordinary meetings wo include 
addresses, discussions, demonstrations, papers. These 
last aro various in character, narratives of experience, 
onrions, or rare, or instructive cases, new remedies, new 
instruments, and the results of observation and research. 
In the cooncil and in committees, besides the arrange- 
ment of business, much useful work is done of a political 
or semi-political kind ; and I shall follow a precedent, 
which seems a good one, in devoting the few remarks I 
propose to make to some important and interesting 
political matters. 

VOL. xziu. 5 



66 INADQURAI ADDRESS. 

This Society has already interfered powerfnlly, and 
with advantage to the public interests, in various medico- 
political affairs ; and there are some measures, especially 
that relating to the education and registration of midwivea, 
which it has already done mucli to promote. In the 
present etate of the condact of legislation we can have 
little hope of success in Parliament unless we secure the 
approval and active operation of a Minister of State, and 
in this we should probably have no difficulty if we could 
make for the minister a quiet political bay in the busy 
and often turbulent session. We do not wish for our 
affairs the parliamentary prominence of party questions, 
and we have no means of quickly convincing our legis- 
lators of their very great importance. We have, therefore, 
reluctantly to submit to the patient waiting for a more 
convenient ministerial season, a time of which we at present 
flee no immediate prospect. 

Before proceeding, however, I must devote a few 
sentences to explain the kind of importance to be attached 
to the political proceedings of this Society, Their place 
in the first words I address to yon might be supposed to 
indicate that the Society claims for them & position 
paramount ; and this would be a very great mistake. 
The Society knows well that political interference is a 
mere accident of public utility arising from the position it 
has otherwise attained. The great work of this Society 
is not political. It is not initiated nor fostered by 
Ministers of State; and it would be fatal to oar best 
interests to wait upon auch un congenial influence. 
Obstetrics and gynecology have been advanced to their 
present eminence and power and usefulness exclusively 
by the labours of comparatively humble medical men. 
As it has hitherto been, so in the future it mnst be. If 
we look to the gradual progress of our department of 
medicine we observe little else than a series of scientific 
papers bearing the names of our obstetric heroes. A 
great practitioner, distinguished for learning, sagacity and 
power, may for a time maintain posthnmoaa fame ; but. 



nUOQUB&L ADDBEBS. 



07 



for the most part, practitioners and practices, books and 
instramenta, have been lost in oblivion. Imperishable 
remain the small scientiBc papers that have tanght us, 
and will toach all future medical students, the anatomy of 
the pelvis, the anatomy of the gravid uterus, the anatomy 
and physiology of the unimpregnated female, the mechanism 
of natural delivery, obstetric auscultation, obstetric anEss. 
thesia, tho mechanism of uimatural delivery, and others 
too numerous to mention here. The wisest judges of our 
Society will pay but scant attention to oar pohtical pro- 
ceedings, and so also will onr best members. The basis 
of onr prosperity and greatness is the unobtrusive memoir 
embodying thought and work and recording distinct 
results ; and we must admit that such papers are often 
dreary affairs as they are languidly read to benchesnot over- 
filled. The man who sends us such — generally a young 
man — must not be discouraged : his paper will command 
wide recognition ; and, although worldly esteem and 
prosperity are but secondary objects in his view, his good 
work will he, as long as he lives, an increasing force tend- 
ing to his promotion in these respects. It is enough to 
say of him. He was the author of that I This Society will 
pay due attention to its political work as it arises, but it 
must devote its best energies to its scientific work. With 
the amount and quality of this it may be pleased, even 
delighted, but it can never be satisfied. Scientific 
appetite and greed grow with the food supplied. Every 
new contribution widens tho prospect and increases the 
demand for yet more. 

Much interest has been and is now expressed and 

I widely felt in the Improvement of the Medical Curricalum, 
and our department of the profession is indebted to our 
late President and to Dr. Macnaughton Jones for their 
enthusiastic advocacy of its claims. With especial force 
is it insisted that the course of midwifery lectures required 
by the corporations is inadeqaate, and while on this point 
there is, so far as 1 know, no difference of opinion, I am 
sure that, in the whole matter, we have the sympathy of 






bo INAUQITfiAL ADDRESS. 

all men of progresB. In considering it, the distinction 
should carefully be maintained between the theoretical and 
the practical, between what is desirable and what ia 
feasible and attainable, and this ia not always done. For 
instance, it is common to say that from every student there 
is or there should be required evidence of a thorough know- 
ledge of this or of that, and, among othei's, of midwifery 
and the diseases of women and of newly-born children. 

Now, it ia only a very moderate amount of knowledge 
that is now or ever will be required ; and it is in vain to aim 
at more. It is not necessary to have experience at exa- 
mining boards to get assurance of this; for, after more 
than thirty years of unceasing atudy and practice, my own 
knowledge of the subjects is auythiug but thorough. 

It ia a moderate amount of elementary knowledge that 
is I'equived of a candidate for licence, and he is expected, 
nay, in duty bound, to cultivate it so aa to produce the 
maturity of a good general practitioner. Within a limit 
of forty lectures, it is impossible for the teacher to give a 
good introduction to the elements of his subject; and 
yet it ia not to be forgotten that the beat teacher is he 
who condenses most successfully ; who, knowing what is 
essential, what is of high importance, fixes on a well- 
arranged and, if possible, u consecutive aeries of facts and 
principles, and carefully indoctrinates his pupils in them. 
In any other sense a complete course is not desirable. Oop 
lecturers should be neither schoolmasters nor grinders. 

The history of teaching surely indicates that in this 
matter we shall, in due time, get what we want. If we 
are true to ourselves and increase the science, room will 
be found for the teaching of it. Our glorious ancestors, 
Smellio and William Hunter, taught midwifery and 
women's diseases from love of and respect for the subject, 
as those teachers do now who give far more than the cur- 
riculum requires ; and so tt will always be, Smellie's and 
William Hunter's courses were not required by the 
licensing or unalogons boards of their day, and they pro- 
bably never reached the length of twenty lectures. We 



lNi.nQURAL ADDRESS. 69 

hsve got far beyond this, Laving compulsory courses, 
which in some schools must reach one hnndrod lectures, 
compulsory actual practice of students, clinical teaching 
and lectures, and instruction in instrumental delivery. 

In settling what should be our demands in respect of 
compulsory attendance on lectures, we must consider our 
position in relation to medicine proper and surgery proper. 
The solidarity of medicine, surgery, and midwifery is a 
popular and a true argument, and justi&es oar claim to 
equal honour and consideration for the three branches. 
But while this claim is now at length — thanks to the 
unaided achioremonts of obstetric science — undisputed, it 
does not follow as a consequence that equal time should 
be allotted to the teaching of the three departments. ^ 
Medicine and surgery are each larger than our depart- 
ment. They were taught systematically before midwifery ; 
and, as a result of this historical fact, their teaching 
embraces large and important subjects, such as the doc- 
trines of inflammation and fever and injury ; which, though 
obstetrical as much as they are medical or surgical, yet 
are not uselessly repeated in courses of midwifery, being 
left in those older departments of teaching to which ours / 
is an addition. 

But the points to be regarded in this somewhat complex 
subject are not exhansted. Time is short, and wo must 
reflect on the age to which wo would have a medical 
6tudent'& education prolonged. The curriculum requires a 
period of about four years, and is already eo filled that more 
can scarcely be crammed into it. Without an extension of 
the curriculum to five years, it appears to me vain to hope 
for a thorough and fair rearrangement of the various 
times allotted to the various oonrses ; and auch an exten- 
sion is a matter for very full consideration with a view to 
the interests, not of students only, but of the State also. 
It is not a mere mechanical question — so much time avail- 
able, so much attendance on lectures possible ; for it has 
been widely asserted, and with some show of reaaoo, that 
present extended curriculum is a, failure, not only not 




70 



IHAUQDBAL ADDKESE, 



yielding reanlta in pr<^)ortion to the extension, bnt pro- 
dncing only increase of crtiin and dangerous pretence of 
knowledge. With this view I do not coincidcj but it puts 
in a clear way the evils attendant on attempting too much. 
When we increase the curricnlnm we must consider not 
only the time available, the age to which the study should 
be prolonged, but also the digestive power of the average 
student's mind. The prodaction of pedantry is. to be 
shunned. 

As members of this Society, we have observed with deep 
concern those discussions in the Medical Council which 
relate to the Place, in the education of our medical practi- 
tioners, accorded to Physics and Chemistry, and we cannot 
besitate to express our sympathy with those who wish for 
these branches of science a paramount position among the 
not purely professional. For Greek or Latin we have no 
special occasion to contend, because the obstetrician or 
gynsBcologiat has never occasion to make use of them 
unless for some purely literary, not scientific or practical 
purpose. Although it may well be asked, what interest 
have the legal guardians of the education of our practi- 
tioners in Greek or Latin, it may, on the other hand, be 
confidently asserted that their place and power in the 
higher education of all men need no defenders nor sup- 
/* porters. These languages are not necessary for a medical 
practitioner, and this cannot be said of physics and che- 
mistry. As obstetricians or gynEOCologists we can neither 
comprehend what has been achieved in the past, nor can 
we have any hope of future progress without the aid of 
the latter. Latin and Greek may be said truly to have 
much the same place in higher general education as ana- 
tomy has in medical education, for through them pass the 
roots of our language, our philosophy, our arts, and our 
sciences. But while high culture cannot exist without 
Latin and Greek, excellent practitioner ship, such as the 
Medical Council has to care for, may flourish without them. 
Latin and Greek will always be studied by the highest 
class of medical men, and will always command an equiva- 



INAUGDBAL ADDKSSB. 



71 



I 



I 



am o£ power and inflaence, and even of the gross 
reward of money. PbyBics and chemistry mnat be stndied 
by all good medical men, and knowledge of them is one 
gnarantee of good practitionerahip. 

Were this a proper occasion I might enter afc length on 
the history and the present bearings of this important 
matter, but I shall confine myself to a very few historical 
remarks, which may encourage the aopporters of what we 
regard as indlspatably the best direction of medical legis- 
lation. Even anatomy was once in the insecure and 
neglected position in which physics and chemistry now 
are. 

Although physics and chemistry are not depreciated or 
lightly esteemed, their supporters have stitl to struggle to 
secure for them their proper place ; and medical history 
points surely to their still farther rising importance in 
medical education. The problem was well understood 
and the conflict stoutly maintained a centnry ago, and the 
too successful ringleader then was the great Stahl, who, 
while he despised and opposed anatomy, fought ardently 
against the introduction into medicine of mechanical and 
dynamical theories ; and, upon the whole, Stahl gained 
the day, that is, he, in this matter, carried with him the 
majority of great medical men. Tmth, however, is 
invincible, and in spite of Stahl and his followers, oppo- 
sition to mechanical, chemical, and dynamical theories 
has gradually become less and less till now the whole of 
the psychicij school is extinct or survives in defence of 
the comparatively very narrow influence of what are now 
called vitalist doctrines. Of these profound doctrines and 
ot their great supporters we speak only with naqualified 
respect. Their existence and extensive power, as now 
exercised, are in no manner a protest against the great 
and due influence of physics and chemistry. 

So great has been the progress of physical, chemical, 
and dyoamicBl theories in obstetrics, and in the other 
branches of medicine in our own days, that it is necessary 
still further to explain historically the reluctance, even now, 



12 IKACGURAL ADDRESS. 

to admit their rising power and utility. Most of us here — 
at least most of those who have even a few grey hairs — and 
most of the members of our Medical Council, were reared 
under the potent empire, not of Stahl, but^ of theories 
more or lees exclusively metaphyaical like his. Not a 
few of U3 imbibed our first lessons in medical science at 
the feet of the venerated Alison, the greatest medical philo- 
sopher of his day ; and as we love the memory of the man 
we ai'O alow to disparage any part of his teaching. Yet his 
teaching, that is, what was instilled into us so recently, ia 
already so obsolete in kind, though not antiquated by mere 
lapse of time, that you will scarcely believe that these are 
his words, " When we compare (says he) the general 
notions as to medical science which are prevalent at the 
present day with those which are recapitulated by Dr, 
Culten in the introduction to the last edition of hia 
* First Linos,' as holding their place, up to hia time, in 
the schools of medicine, the most important observation 
that occurs to the mind is tho present general, although 
not always avowed, recognition of this principle, that 
the phenomena of disease, like all other phenomena of 
living bodies, belong to a class of factSj and constitnto a 
subject of investigation, altogether distinct from those 
which are presented by any forms or changes of inanimate 
matter. Dr. Cullen states that the mechanical philo- 
sophy had been applied (soon after the discovery of the 
circulation) towards explaining the phenomena of the 
animal economy, and continued till very lately to be the 
fashionable mode of reasoning on tho subject ; and he very 
properly admits that it must 'still in some respects con- 
tinue to be applied,' but he adds that ' it would be easy 
to show that it neither could, nor ever can be, applied to 
any great extent in explaining the animal economy. 
Now, an important step (Alison continues) has been already 
made in the progress of medical science, when this pro- 
position has received the general assent of the profession, 
and when the study of mechanical philosophy is recom- 
mended to the student of medicine, not as one of tho 



I 



t 



INACJOUHAL ADDBE98. 78 

foccdations of medical scieDce (with tliB exception of a 
few simple applications of its principles in some parts of 
phyaiology), but simply as an example of succeasfnl inves- 
tigation. A nearly similar observation may be extended 
to the subject of chemistry; for althougli it be tme that 
all vital actions ure attended by, and in part dependent on, 
a series of continuat chemical changes, and although a 
certain knowledge of chemical principles is therefore 
required of the physiologist, yet the chemical changes of 
animated nature are as distinct from those which we pro- 
duce at pleasure in ^ead matter, as the stimulation by 
nerves and the contraction of muscles are distinct from 
any of the principles and powers of mechanics," 

If physics and chemistry were in this slighted state 
forty years ago and have now risen to jostle Greek and 
Latin in their time-honoured places, what may we not 
expect from the progress of science within another forty 
years? There is no reasonable doubt of their growing 
into pre-eminence, and it is to be hoped they will not treat 
rudely the stndy of those languages which are the 
favourites of all that are scholastically disposed. For 
physics and chemistry we ask no favour, only justice, at 
the bands of the Medical Council. 

The Registration of Disease is, as yon are aware, making 
groat progress in isolated parts of the country, and its 
universal adoption may be expected in no long time. 
Before this time comes, imperial legislation may compel 
iti and it is almost certain that further legislation with a 
view to prophylaxis will bo a valuable fruit of the increased 
knowledge provided by the system. There are many ways 
in which such prophylactic legislation may interest us; 
and it is in the highest degree imperative to prepare for 
it and to watch it, so as to have the laws wisely framed 
for the public good. Puerperal fever will, no doubt, be 
the chief class of diseases in our department for prophy- 
lactic legislation ; and it may be expected that we shall 
be able to give deoided testimony as to the value of oar 
plans. Antiseptic cares are already in some parte qf 



74 



mAUGUBAL ADDBZSS, 



Germany reqnired by law or reoommended to midwives 
by those who have a legal right to command them ; and 
it is to be remembered that, in that country, almost the 
whole of midwifery is in the hands of midwives. 

It ia evident that, in this country, we have been passing 
through a period of alarm, allied to panic, arising from 
newly-acquired knowledge of the greatness of the evil and 
ignorance of its nature and mode of propagation. This 
prolonged panic has naturally led to extravagant views 
and to grave injustice especially to midwives and to 
hospitals. Obstetric science is gradually disclosing the 
nature and prevalence of the diseases classed under the 
name of puerperal fever, and this work has been done 
chiefly under the guidance of those antiseptic theories 
which have produced such grand results in medicine and 
surgery as well as in midwifery. It is to antiseptic 
theories also that we owe our most trusted resources in 
practice, resources whose value ia demonstrated beyond all 
doubt, and which will soon, I believe, be ao generally adopted 
as to command the consideration of those interested in pro- 
phylactic legislation. 

But I wish, at this early time, to put in a plea for 
another prophylaxis, the Legislative Protection from 
Syphilis especially of women about to be married and of 
doctors. It is not rare to meet with instances of care- 
lessness, on the part of bridegrooms, so gross as to merit 
the imputation of criminality; innocent women being, as 
a result, infected with syphilis and thereby killed or 
maimed for life, and their offspring in a like terrible 
plight. No doubt such tragedies are sometimes enacted 
in spite of due care on the part of the husband ; but many 
are the result of culpable thoughtlessness or culpable 
neglect. Again, in my own medical circle I have lost, 
tbrough accidental surgical infection with syphilis, several 
medical brethren whose lives were very valuable. One of 
them, an accoucheur, did not survive attendance on a 
syphilitic lying-in woman above a year and a half. Now, 
it appears to me that such proceedings as the marriage of 



I 



IHAnaUBAL ADDHESB. 75 

a man who knows he has recent and active syphilitic 
disease should be taken cognizance of hy the law and 
regarded as a crime, not mnch less grave than man- 
slaughter ; and the same is true of such proceedings as 
that of a lying-in woman who, knowing she has syphilitic 
sores on her pudendum, fails to warn her accoaoheur of 
the circumstance. Disease and death, coming in this 
deliberately careless way, rarely involve not less horrible 
and heinous criminality than any other oSence. 

The Education of Women for the important profession 
of midwifery has long been carried on, in many quarters, 
in these countries, with more or loss of completeness] and 
with very good resnlts. It had been and is the custom 
to give to pupils a course of lectures, and to require prac- 
tical instruction and some erperienco before conferring a 
diploma or certificate of competency to manage ordinary 
natural labour and puerperal state. Nearly ten years 
ago, this Society prescribed a modest curriculum for pupil 
midwives, and established an examination to teat their 
attainments with a view to granting a diploma to such as 
gave satisfaction to the Society's examining board. This 
good scheme has had an encouraging amount of success, 
the numbers passing in each year, from 1872 to 1880 
inclusive, being 6, 11^ 4, 2, 3, 4, 5, 12, 22. But this 
does not satisfy us. We want a recognised legal 
position, chiefly registration, for graduates, and we desire 
a great increase of the numbers taught and seeking onr 
diploma. 

In some foreign countries, to which we look as 
examples for consideration rather thnn imitation, the 
education, registration, and regulation of midwivea bos 
long been carried on with apparent satisfaction to all 
parties. You all know the text-books for midwives iesuod 
under Government auspices in Germany. I have brought 
with me the book of the rules of midwifery service in the 
Kingdom of Wurtemborg, issned by authority of the 
Minister of the Interior. I also show you the remu-kably 
cheap, handy, and useful obstetric bag which ia recom- 



76 



mAOODRAL ADDRESS. 



mended to midwives in that kingdom. Foreign ob3tetrie 
conditions are, as I have already said, very different from 
those of the United Kingdom, and of course the Govern- 
ment arrangements aro not exactly what we should desire 
for oor country, with its limited employment of midwives, 
and what we consider the freer spirit of our laws. 

Our examination systein has recently been extended by 
the Society empoworing its honorary local secretaries to 
conduct the written examination. This diminishes the 
expenseB of candidates by reducing greatly the number of 
days spent in London ; a single day for viva voce 
examination being now sufficient. 

That this widening of the area of easy working of our 
midwifery system is a good proceeding I have no doubt. 
Indeed, the improvement and extension of the practice of 
ordinary midwifery by women ia a most desirable object. 

/Many people still living remember the time when the 
whole of this practice was in female hands. It was taken 
from them not by the other sex because they were male, 
but in consequence of their superior education and 
scientific attainments. Science overthrow all the pre- 
judice against man -midwifery, and this was not a small 
matter, for authority as well as prejudice were, at one 
time, so strong on the side of women aa to bring Dr. 
Wertt to be burned at the stake for attending a woman in 
labour. If women are to be reinstated in the practice of 
midwifery, whether in unnatural or in natural labour, it 
is education and science alone that can do it, and women 
may be sure that these are irresistible. Meantime we are 
interested only in the extension of women's usefulness in 
ordinary cases, natural or nearly natural; and our object 
is to secure for the public a class of such women, reliable 

\ because duly qualified. The gain to the greatest number 
will be considerable, for the service of midwives is of 
courae got at a less rate than that of fully educated practi- 
tioners, whether male or female. Besides, such fully 
educated practitioners are gainers, for their time and health 
are so valuable and rapidly increasing in value, as to make 



INADaoEAL iDDRESS. 



77 



it a very bard struggle to do full justice to their cases. 
Every one knows how necessary patience and long waiting 
aro for the performance of midwifery duty ; and no one 
is proof against the bias given by impalses of time and 
health. The more extensive employment of midwives will 
greatly improve the care of the poorest and largest class. 
Such women are comparatively easily remnnerated ; they 
go to their cases unembarrassed by other important and 
pressing engagements ; and they expect, without regard 
to the nature of the case, to have a stay greatly longer 
than ia anticipated by the fully qualified practitioner. 
Against advantages there are no doubt disadvantages, and 
here, as in innumerable other difficulties, we make the best 
attainable compromise. 

We have, naturally, been disappointed at the political 
delay of our scheme for the education and registration of 
midwives; but wo are not discouraged, because wo have 
no active opposition, and the urgency of the matter is 
daily increasing. Indeed, if we consider the gradual 
growth and progress of all such schemes in this country, 
and the still only partially developed state of our own 
midwivea' arrangements, we may even assume that the 
delay does not involve loss of time, but will add, when the 
proper opportunity comes, irresistible force to our appeal 

■ to the Government. 
We shall, no doubt, carry with us the sympathy, we 
hope also the active support, of the Medical Council. This 
medical parliament, embodying as it does the political 
knowledge and experience of the profession, will surely do 
its duty by us ; for it has hitherto shown itself wisely 

Inealous for the interests of th* public, not hesitating, 
after duo consideration, to go beyond its chartered daties 
when each interests pointed the course. 
The presence in the Council of an Obstetric Member has 
never beeu indispensible, yet always desirable ; and the 
deficiency of such a member has been keenly felt, and, of 
course, most by us whose interests are especially dear to 
ourselves. When the education and registratioa of mid* 



I 



78 



UfADODK&L ADDRESS. 



wives cornea within the range of praxitical politics, we 
tritat an obstetric member, or obstetric members, will be 
in the Council to give aid. 

On the death of Dr. Hadson, yonr Council seized the 
opportanity to memorialise the Government with a view 
to the filling of the vacant place by an obstetrician, and I 
am happy to tell yoa we have gained our end, for I 
have a letter from the Lord President of the Conncil, 
assuring me that the wishes of the Society will be carried 
out. 

Yon are all well aware ot the preparations that are being 
diligently carried on for the Meeting of the International 
Medical Congress in the Metropolis in August, and, no 
doubt, take especial interest in that part of it called.the 
Section of Obstetric Medicine and Surgery. The general 
and executive committees of the Congress have nomi- 
nated for the Section a president, vice-presidents, council, 
and secretaries, embracing a large number of distin- 
guished physicians, whose names will certainly command 
the confidence and respect of our brethren both at home 
and abroad, 

The importance and usefulness of such meetings as thia 
call for no remarks, for their very existence is, in itself, 
almost a sufficient demonstration of them. We are living in 
an epoch of great development of scientific parliaments, and 
no one dares to predict, though he may rejoice to antici- 
pate, to what good result this will lead. Scientifio 
societies have flourished in great towns ever since the 
revival of learning. National scientific meetings hare 
been regularly catabliahed only within our own times, or 
are being established sow. But this kind of progress 
may be said to proceed in a sort of geometrical ratio. 
Political conferences are of comparatively old date, and 
have only a remote analogy with scientific congresses ; but 
the gi-eat industrial exhibition of 1851 no doubt offers a 
striking resemblance to our Medical Congress, and it 
inaugurated an era of international activity, laden with 
many peaceful blessings. 



tNADODRAL ADDBK86. 



79 



I 



I 



Our own Society was started only twenty years ago ; it 
had no perceptible period of infancy or adolcBCOnce, but 
from the first bore the appoarauce and produced the fruits 
of a matare association. Ita founders had, in their eouttd 
judgment, justly estimated what was wanted; for, accord- 
ingly, onr Society has supplied the want and has pros- 
pered. It was not enough to have occasional allotted por- 
tions of the meetings of the Eoyal Medical and Chimrgical 
Society, and a few papers in its annual volume of ' Tran- 
sactiona.' Obstetrics and gyniacology had commenced 
rapidly to grow not only in bulk but also in philosophic 
elaboration. The metropolis required monthly meetings 
devoted entirely to the subject of our practice and study ; 
and this activity ia represented not by a few papers 
of observation in the -'Medico-Chirurgical Transactions,' 
but by an annual obstetrical volume, rich not in mere 
observations and dogmatism, but also in speculation, expe- 
riment, and research. Under the anepices of the British 
Medical Association we have a great annual national 
Medical Oongress which, not many years ago, began to have 
a special obstetric section. But already all this is not 
enough. Professional brotherhood, the jostUng of co- 
operating intellects, the oomparison of results in practice, 
are increasingly osigent. Meetings in all great towns, 
and national meetings, do not supply the demand, and 
now, for the first time, a cosmopolitan Obstetric Congress 
will be held in the greatest city of the world. It is not 
enough to anticipate or wish for great results of this 
August meeting. We must contribute to its success 
according to our opportunity and ability, and every one of 
us can contribute something, if only contagious enthusiasm, 
or mere sympathetic bodily presence. 

Accoucheurs and gyntecologiats are generally styled, 
or style themselves. Physicians ; but they are as much 
surgeons as physicians, and indeed a great authority hatt 
recently asserted, ex calhe'lrii, that they are more surgical 
than medical. I do not think so, and, curiously enough, 
the great authority, althougli President of the Irish 



80 



mADODRAL ADDKEES. 



College of SorgeoDS, is himself ftn iUaBtrions example of 
the preponderance of the medical element. Trath to 
tell, our department is like medicine in general, divided 
into two friendly co-operating campSj the medical and 
the snrgical, and each man is driven into either or 
remains mongrel according to his special genins. Most 
begin by afiecting the simpler and in many respecta 
easier line of surgery, but mosl end with the conviction 
\that they have not the rare surgical genius. At present 
the strong currents in obstetrics and gynsecology are 
rushing in tho snrgical direction, and too strongly bo in 
the opinion of many intelligent observers. But it ia 
foolish to deprecate this progress and vain to attempt to 
change it. The unknown laws of the growth of our 
departments of science and practice are not to be bent 
according to our short-sightedness to suit our views. 
Tho present surgical wave is undoubtedly doing good, 
and we cannot avoid its sweep, although wo might wish 
it were less strong or had its medical equivalent. 
Accordingly, in the international obstetric programme it 
will be found that, for this year at least, surgery ia 
paramount, yet not drowning far leas excluding medicine. 
There is, indeed, still plenty of sectional time and space 
for medicine to occupy and reassert its preponderance 
over surgery. The authorities of the Congress invite 
you, as well as foreigners, to come forward with such 
results of observation, experiment, and research, as you 
may have to offer for the consideration of the cosmopolitan 
assemblage of brethren who will have come for this 
purpose from all parts of the world. Every student is 
aware of the considerable differences that exist among 
the nations in their mode of describing and discussing 
the same obstetrical and gynecological matters. This is 
well illustrated by text-books. A German or French 
manual, even if undoubtedly far superior to an English 
one, cannot be made by clever translation to take its 
place. The foreign work does not fit into our literary 
system, and it proves valuable, chiefly by being mentally 



J 



ON THE BO-CALLED "MISSED LABODK." 8] 

assimilated by British readers, and thus ' made part and 
parcel of our historical Britisli literary developmeiit. If 
the differences among British obstetricians are enough to 
give a varied interest and instrnctivoness to onr meetings 
here, how much more of striking and useful variation may 
wo look for in an International Congress. We may 
expect to get, not only original and new instruction, but to 
be ediiied by having old things shown us in a new light. 
To conclude, gentlemen, while in medical politics this 
Society is working for the good of others, each member 
has to consider how he can make the Society itself 
greater, and himself more useful through it ; and his 
spirit should be that of the happy warrior — 
" Wbo. if bo rise to station of commiuid, 
Biiea by open menus; and tbere will Btnud 
On houounible torma or el»e retiro ; 
Who comprcheuiLi liii tnut, unci to tbe aumc 
Keeps fuithtU witli a singleness of kim ; 
And thvrufore iloea uot gUwp, nor lie in wait 
For wenltb or LoDuur, or for worldl; state ; 
VVLoLU they must follow ; on vrbose hsAi must tall. 
Like sbowera of uisiuui, if the; come at nil." 

A vote of thanks to the President for his interesting 
address was proposed by Dr. Bobebt Barnes, seconded by 
Mr, Spencbb Wells, and carried with acclamation. 



ON THE SO-CALLED " MISSED LABOUR," WITH 
A CASE IN ILLUSTRATION. 



By RoBEHT Baenks, M.D., 
oDsnmuo puxsidiah to bt. asoRaa'a hobpital. 



Bbfobe entering upon the discasaion of the subject of 
" Missed Labours," it is necessary to define what in meant 
by thia term. It was first used by Oldham, and it has 
become classic, but its scope is not well defined. 
Under the title " missed labour," oases differing widely 

VOL. ssui, 6 



82 OH THB BO>CALLED " mSSED LABOUB. ' 

in nature h&ve lieen incladed. This looseness of classifi- 
cation is the expression of the uncertain state of science 
in what relates to the retention of tho fffitns under 
difEerent circumstauces. When these circumstances and 
the histories of the presamed cases of " missed labour " 
are subjected to rigid criticiamj the question will be 
forced npon us : whether after all such a thing in strict 
meaning as " missed labour " in the sense implied by 
Oldham has been proved to exist, Oldham's proposition 
was that a fcetua might reach its full development in the 
uterns, and, living at the full time of gestation, a distinct 
parturient effort might be manifested and pass off, the 
ftetns being retained for a considerable time longer in 
the uterus. I think we have still to wait for a case 
in proof. Certainly, Dr. Oldham's case is not such a one. 
The minute examination of the parts made by Dr. Wilts 
proves that it was a case of extra-uterine fcetation, in 
which the bones of the fcetus had made a way through a 
fistulous track from an extra-uterine cyst into the uterus. 
In this sense, then, the term " missed labour,'' seem- 
ingly BO happy, and which has so fascinated tho minds, of 
obstetrists, is bereft of meaning. If the term is to be 
retained, it must be applied to cases of a different nature. 
■ Nor is the statement of McClintock' free from ambiguity. 
He says : " The term " miaaed labour " has been applied 
to a class of cases of uterine pregnancy in which, through 
failure of parturient action, the fcotus is retained for 
some indefinite period beyond the term of natural 
gestation. In every instance the icetus has apparently 
been dead at the time when labour should have taken 
place, and the waters of the ovum have generally been 
discharged about this epoch or previously." He goes on 
to say that " cases of missed labour are amongst the very- 
rarest in obstetric practice ; " and then relates, with all 
his well-known care and sagacity, " the history of a case 
of this kind." I cite the summary of it in McClintock's 
words : " The subject of it had given birth to twelve 
■ Oablia OtwtetriMl Sodetf , lS6i. 



I 






ON THE 90-CALLED " MISaKD lASOUR," 83 

liTiiig children, then to a dead child at full term, aoon 
after which she conceived for the fourteenth and last time. 
On this occasion gogtation proceeded naturally till about 
the seventh month when symptoms occurred leading her 
to believe, and rightly, ao far as I can judge, that the 
fcetus died at this time. Nevertheleae, pregnancy went 
on to the end of the ninth monthj when, exactly at the 
expected time, paina like those of commencing labour set 
in, and there was some discharge of blood and water. 
These Bymptoms of labour soon passed away, and preg- 
nancy went on without any onusaal circonutance for Jiv» 
weeks longer. She was then seized with severe puu^ 
that she described as labour pains, which continoed for 
two days without cessation. A very experienced prae- 
titioner found her suffering under hemorrhage and great 
pain, and discovered a bone in the vagina, which he 
removed, and which proved to be a foetal rib," Fetid 
discharge went on, and McClintock proceeded to remove 
the remains of the foetus. This was done at several 
sittings after dilating the cervix uteri by tents. On one 
occasion Dr. Hardy, " with much trouble, extracted two 
long bones, like a femur and humerus, which seeined lo have 
been, partially embedded in the tissue of the ittenis." 
These operations were carried ont sixteen months after 
the attempted labour. The woman died under symptoms 
of septiciemic peritonitis. No autopsy was made. This 
is much to be regretted. Autopsy might have averted 
the doubt that arises whether this case, too, like Oldham's, 
might not have been one of extra-uterine gestation. And 
recovery might, as in my case presently to be related, 
have permitted further observations to be made on the 
uterus and surrounding parts when cleared of the preg- 
nancy. MiiUer,' in a valuable memoir, has subjected moat 
of the recorded cases to a keen analysis. He insists that 
this case was in all probability one of extra- uterine 
gestation. Independently o£ the contidence which 

De I> groueaie uUriue prolongee utd^SnimeDt, " miswd Ubooi" des 
AnglRit,' pw Dr. E. Muller, FuU, 1S78. 



84 



ON THE BO-L'ALLED ' 



McClintock's autbority inspires, bastag upon some pointfti 
in the history of his case, and upon the history of the 
case which I shall presently relatOj 1 cannot unreservedly 
share the opinion of Miiller. I think it will appear that 
whilst we have still to find an unequivocal case of prolonged 
retention of a foetus in iitvro which had lived until the 
full term of gestation, we cannot deny the possibility of 
the prolonged retention ui idero of a fcetus which bad 
perished some time before the natural term of gestation. 
And this is McClintock's contention. The other cases 
McCliutock cites : as Montgomery's, Cheston'a, Deweea', 
Nebelin's, Schultze's, vsn Dorfer's, Caldwell's, Voigtel's, 
all, I think, melt away into instances of extra-uterine 
gestation under Miiller's searching analysis. 

The hypothesis of miaaed labour, then, brings us face to 
face with the following problema : 

1. Can tho fcetus livin-g at term be indefinitely retained 
in the uterus V 

'2. Can the fcetus dying sotni; time before term be 
indefinitely retained in the uterus ? And linked with these 
problems there come the questions : — What is the normal 
duration of gestation ? What is the cause of labour? 

Since these problems will receive some illustration, if 
Hot their solution, from the case which forms the motive 
of this memoir, it will be convenient to relate the CEtse 
here. 

A lady came to me from Penang under the doubtful 
impression that she was suffering from nterine tumours. 
The history down to the time of her coming under my 
Care is condensed from tbe statement of Dr. Yeitch. 

Mrs. B — , set. 39, had borne three stillborn children, tho 
last of them five years before consulting Dr. Veitch at the 
end of December, 1872. At this date she stated that the 
catamenia had ceased since the early part of October, up 
to which time she had been quite regular and in good 
health. The cessation of the catamenia was followed by 
morning sickness, lassitude, repugnance to certain articles 
of food i the breasts increased in size as wtiU as tho abdo- 



JU. 



I 



ON THE SO-CALLED " UIBSRD LABODB." 85 

men. Between the third and fonrth months she diatinctly 
felt " quickening." After the 18th Jone, Sorgeon- Major 
CHalloran attended for Dr. Veitch, and gave him the 
following accoant : — Up to the seventh month Mrs. B — 
felt what she took to bo the movements of the child. 
Abont the eighth month she bad a slight accident on 
stepping into her carriage, bnt this Dr. Veitch thought 
had no injurious effect. Between the eighth and ninth 
months there was a flow of blood from the vagina, and 
labour was supposed to have commenced ; ho labonr-painn 
however BOt in, and on examination the uterus could 
scarcely bo reached by the finger ; the os was found un- 
dilated, but softer and more flaccid than normal. Under 
rest and use of cold and styptics the hfomorrhngo ceased 
in a few days. At the end of three weeks bleeding 
returned to a very conaidorable extent ; still no labour- 
pains. Iced enemata wore need ; tannic acid was found most 
useful in checking the discharge. At tho end of a week 
the discharge was lighter, and then gradually disappeared. 
Auscultation revealed no sonnds. Early in September, 
that is, eleven months from the presumed date of con- 
ceptidn, Dr. Veitch examined with the same result. The 
uterus as felt through the abdominal walls appeared to be 
smaller, rounder, and harder than is usual in pregnancy. 
Moreover, there was an irregularity to be felt in the body 
of the uterus, more particularly on the left Bide. The 
mouth of tho womb could scarcely be reached, but as far 
as Dr, Veitch could discover it was soft, doughy, yielding 
to the touch. Throughout all the patient's general health 
and appetite had been good, except for about ten days, 
when her appetite failed in consequence of the emotion 
caused by lier having boen informed that it was necessary 
she should proceed to Europe for change of air and further 
advioe. She was of an extremely nervous temperament, 
easily cast down. This mental distarbnnce brought on a 
retnni of hiemorrhago, but in a slight degree. Three 
weeks later, in consequence apparently of a slight dis- 
appointment, she bad another '* retam of hatmorrhage." 




86 ON THE BO-CAILED " KTSBBP lABOUE." 

Mrs. B— came under my care in December, 1873, On 
the 30tli the uterus was felt rising as high as the umbilicus, 
very hard ; its walls gave the impresBJon of being very 
thick. It thus simulated fibroid tumour, for which, in 
fact, it had been taken. Under chloroform, the cervix 
having been previously dilated by laminaria tents, I 
thought I could touch the whole interior surface of the 
uterue ; everywhere it felt smooth ; the sound passed six 
inches. In January, 1874, she wore an abdominal belt 
with comfort ; some coloured discharge went on, but not to 
the extent of flooding. At the end of January pieces of 
bone, which turned out to be bits of spinal column, came 
away day by day. Having partially dilated the cervix by 
laminaria tents simply, and iu faggots on the 23rd January, 
I took away by finger and forceps three more bits of bone 
from inside the cervix, The ■uterus at this time still rose 
as high as the umbilicns. Mr. Spencer Wells now saw 
her with me. We both felt the compressed fcetal mass 
with bones on the surface inside the cavity of the utems 
proper. 

Offensive discharge continued to flow for some days. 
In February, under chloroform, and aided by Dr. Fanconrt 
Barnes, I proceeded to empty the uterus. The fcetns was 
removed with great difficulty, owing to the rigid state of 
the cervix, which had yielded imperfectly to the action 
of tents. The hand could not be got through the cervix, 
so I extracted, by ray craniotomy forceps, the foetuB. 
The fcBtus was a compressed mass, bones emerging on 
surface, the fleshy part greasy, soft, and putrid. It pre- 
sented the appearance of having reached the eighth or 
ninth month of gestation. The patient showed consider- 
able prostration after the operation. She had rallied next 
day. She bad daily injections, intra-uterine, of chlorozone. 

On the 2nd March she was much better. Shreds of 
placenta came away daily ; the abdomen became more 
flaccid and not tender to touch ; the fundus of the uterus 
was felt ajsout midway between symphysis and umbilicns, 
and the discliarge became leas offensive. The general 



ON THE 90-CALLED " MISSED LABOUE. 



87 



state improved daily. The cervix remained open, the 
uterus contracting alowly and gradually. On the 10th 
March the uterus measured five inches from the ob exteroum, 
the point of the sound being felt at the fundus through 
the abdominal wall. For some days more shreda of 
placenta continued to come away on injecting. 

She went to BrightoUj and in May the uterus had 
recovered its normal bulk and other normal conditions. 
She returned to Penang, whence I heard that she was in 
enjoyment of good health. Menstruation had returned. 

Appreciation. — To construct a theory which shall bind 
all the ascertained facts into a consistent history free 
from dispute is perhaps impossible. One thing, however, 
ia certain to my mind, namely, that I removed the fcetua 
from the cavity of the uterus. I several times had my 
fingers through the cervix and, by external pressure, I 
could feel them against the fundus in the uterine cavity. 
I traced the gradual contraction of the organ after empty- 
ing it down to the normal state of tBe nou-pregnant uterus. 
This was done by the combined use of the sound and 
palpation. It must, then, be assumed that it was a case 
of intra-uterine gestation, and not one of ectopic gesta- 
tion, the fostuB making ita way by ulceration from a sac 
outside the uterus into the uterus or cervix. An im- 
portant point to determine is the age at which the foatus 
perished. The beat evidence ia given by the development 
of the fcBtus. This pointed to at least eight months, and 
this would tally with the history. The catamenia ceased 
in October, 1872, early; this was followed by the usual 
signs of pregnancy. This, then, is a fair presumptive 
departure for the pregnancy. This date ia confirmed, so 
far as subjective phenomena can be relied upon, by the 
patient's account of " quickening " between three and four 
months later, and her feeling the movements of the child 
at the end of seven months. Then came the slight acci- 
dent at the end of eight months, and a little later the flow 
of blood and the softer condition of the os uteri. Was 
this an attempt at labour T There wore no labour pains, 



90 ox THZ MMIALLKD "iflSSXD LASOUS." 

thesis still lacks verificatioQ by anatomf. It requires 
lijrstenatic resenrcli by experiment, and this research I hope 
ODD day to carry ont, shoaLd opporttinity be giren me, in 
some other land where the mediseral hatred of science is 
extinct or snppressed, where barriers are not set against 
the paninit of knowledge nnderthe dictation of that bar- 
baroQs instinct, ever craving for something to persecnte, 
which itpriuge from the uncontrolled play of the baser part 
of man's nervous system, that ia, of its reflei and emo- 
tional elements. 

The correlated question — What is the natural period of 
gestation ? involves the veied question of protracted live 
gestation, and this has a more direct bearing upon the 
hypothesis of miaaed labonr. I mnst, however, now be 
content with observing that with the progress of physio- 
logy the hypothesis of protracted gestation is crombling 
away. The cases of supposed protracted gestation of live 
children resolve themselves for the most part into errors 
of calculation, the dates of inseminatinn and fertilisation 
of the rmim being confounded, and many other soorces of 
fallacy snrronnding them. 

Without, then, absolutely denying the possibility of a 
living child being carried for a brief period beyond the 
ordinary time of 270 to 2S0 days, still, granting such a 
case, it could not be used as evidence in favoor of the 
hypothesis of missed labour. 

The question as to the retention of a fistus dead before 
term >n lUero is a totally distinct qnestton, and it has 
■TCB more intimate relation to the hypothesis of missed 
Uoor. Stoltz* meets the proposition that a f a?tug dying 
tilRe term may be retained in uiero for an indefinite 
UBS nib a denial as absolute as he does the theory of 
jfOmmati gestation of a live child. This dwelling, he 
ap^,tea> indefinite time of the ovum in the body has 
jpHKi^w the hypotheaia of protracted gestation, much 
4i>'«ipi^ <R fV Cfratnries especially, so long as estra- 



OV THE SO-CALLED " MISSED LABODB." 



91 



I 

I 



nterioe gestation was denied. ThnB, Qnentin Thyvenm, 
1639, argned the thesis, " An fcetus in tuba uteri gene- 
rari possit ? negat." ; Ant. Ruffin, 1658, "An hoffio 
extra-utemm gigni potest ? negat." ; and Lemercier, 1667, 
" Ergo potest infana per plures annoa in utero matrii, 
ejusqae tnbis, sana anperstite muliere conaervari." So, 
starting with the dictum that extra-uterine gestation wai 
impossible, and having to explain the undoubted cases o: 
retention of the foatus in the mother for periods exceeding 
the natural term of gestation, there was no resource but 
to affirm the doctrine of protracted uterine gestation. The 
logic might pass, if the first term of the syllogism were 
not a simple denial of the truth. Still this erroneous 
opinion prevailed for some time longer. Indeed, it may 
be said still to survive in soma of the recent cases related 
as instances of missed labour. 

But since it has been known that conception may take 
place outside the uterus, that a gestation may ensue, and 
that this gestation may in certain cases reach the ordinary 
term, but that expulsion cannot take place, we have solved 
the mystery of prolonged gestations. From this moment 
examples of protracted uterine gestation have become 
extremely rare. This is the conclusion of Stoltz and 
Miiller, and it seems to me incontestable in so far as it 
applies to the prolonged retention of a fcetus that had 
maintained life until the fulness of the natural term of 
gestation. But these authorities go further and doubt 
the possibility of prolonged retention of a prematurely 
dead f(etu8 in viero. They say that most physiologists 
have begun to share this doubt. The case which forms 
the basis of this paper is, I believe, one of retention in 
utero of a foetus dying prematurely, but in all probability 
at a viable age. In so far it approaches the realisation 
of the idea of missed labour. Presently I shall recur to 
the points which appear to establish the truth of this inter- 
pretation. But there is another class of cases, not so 
rare, that demands consideration. I refor to the cases 
where the embryo dies at a prGO-viable age and in retained 



92 OK THB aO-CALLBD " HISSED LABOnB." 

for a time after its death. These Stoltz calls examples o( 
"internal abortion." The term is valuable. They might 
dso be called cases of " concealed or occult abortion." 
The abortion is effected in all but the expulsion. How 
bng may this be delayed ? What becomes of the fcetus 
iying before term and retained in the uterine cavity? 
Can it bo absorbed all except the bones? This ia 
extremely doubtful. Can it be converted into a litho- 
ppedion ? Crnveilhier says emphatically : " Je crois 
pouToir dire que les foetus petrifies n'occupent jamais la 
cavitS uterine." Admitting this, we must exclade from 
this discussion on missed labour all the cases of litho- 
pEedion which have been cited as examples of protracted 
uterine gestation. Roederor's proposition*: "In ipso 
ettam utero foetus quandoque in lithopsedion duresoit" 
represents the belief of a bygone fige. Can the fcetus 
dead in utero undergo adipocerous or fatty conversion ? 
My case seems to prove the affirmative. After a time a 
slow form of decomposition takes place, the soft parts 
melt down, partly liquefy, partly break down in shrods, 
and the bones bared separate. The soft parts are dis- 
posed of slowly, the liquefied parts and shreds may be 
discharged by the cervix uteri and vagina, some degree 
of absorption taking placej as is made evident by the 
signs of toxaemia which arise during the process of elimi- 
nation. Probably the access of a little air ia necessary 
for this process. 

There is a class of cases, of which the oft-cited one of 
Dr. Menziest is a type, in which the dead embryo ia 
retained in. utero owing to disease, in Dr. Menzies' case, 
malignant disease of the cervical-portion. But it oannot 
be maintained that this case proves the reality of iniBsed 
labour. 

There is one condition under which a fcatns dead 
prematoroly may certainly be retained in utern for several 
months. The cases of twins, in which one fostus ia killed 




I 
I 



^^ the 

^^B casei 

mm. 



ON THE SO-CALLED " MISSKF LABOITB. US 

nnder compressiou by the stronger one, are dow well 
understood. No one can misinterpret the beautiful 
drawing in Cruveilhior, whicli represents a mummified 
fcctua of an early stage of development attached to an 
atrophied placenta, together with a, (ull-grown live oliild 
attached to a healthy placenta. Several muBeums now 
contain similar examplea. These cases, at one time 
taken as examples of superfcetatiou, aSord another proof 
how apparent departure from established laws have been 
brought back within their bounds as science has advanced. 
In those cases the mummified fcetus and its placenta 
undergo a fatty or adipocerous transformation. 

I need but refer in this connection to those cases of 
retention of the membranes for some months after the 
death and espulaion of the embryo at an early stage. 
These cases fall within the history of so-called moles or 
degeneratioQj of the placenta. Mole pregnancy presents 
many points of similitude with that of uterine fibroids 
and polypi. The uterus behaves in a similar manner, 
teleratinff the parasitic body naore or less, until sometimes 
efforts at expulsion are made under the recurring menstrual 
epochs. 

This question is closely related to the history of 
" missed labour." Is there a determinate time for the 
retention of a dead embryo in the womb ? This question 
is by no means of easy solotion. Some years ago I 
devoted some time to the study of this point. Examining 
the cases in point which had come under my own obser- 
vation, and those which research into the writings of 
others afforded, 1 came to the provisional conclusion that 
the ordinary time for which the uterus endured the 
presence of a dead embryo might be stated at three 
weeks. It is obviously difficult in most instances to 
define the date at which the embryo perished ; and 
estimates of this kind arc open to other fallacies. In 
defect of positive evidence, it is wiser to repose upon 
the uniformity of the laws of nature. Miiller collects 
cases of retention of ovum of early date at death. 



94 ON THE SO-CALLED ' 



Fabbri, of Bologna,* collected cases in illastratioa. 
But Miiller observes upon them that the anthor nnder- 
stood by " missed labour " the death of the fcetua in the 
mother, and its retention for a shorter or longer time 
in tie nteros. Thia is what Stoltz called " intemal 
abortion." 

The physiological process would seem to be this : — ^The 
embryo perishes, from whatever cause, that moment, 
developmental work ceases, the ciirrent of blood and 
attendant nutrition are turned off from the uterus, and 
involution sets in. Now, involution tabes place in a 
month or less, I believe under ordinary conditions in 
three weeks or less in cases of abortion. This process 
complete, the walls of the uterus press upon the embryo 
and expulsion takes place. Expulsion probably takes 
place in most cases whilst the muscular property of the 
uterus is still active, that is, earlier than , three weeks. 
The ultimate determining factor of expulsion is probably 
the same as that in normal labour, that is, a menstrual 
nisus. In cases where this process does not put an end 
to the retention, then comes the phenomenon often 
observed in ectopicf gestations, also of uterine effort at 
the normal term of gestation. 

The contention, then, of Stoltz and Miiller that an 
aborted ovum cannot be retained beyond the normal 
term of gestation, and that it cannot be converted into 
adipocere, seems to be untenable. 

An appeal has been made to comparative physiology to 
throw the light of analogical argument upon this question. 
Sheep and cows have been said to be subject to missed 
labour; and since their parturient history is specially 
open to accurate observation, we might fairly expect 
• " Del pErto pretarmesao o mencuto nei brnti domeatiri e nella specie 
uiDBQH," ' Memor. dell Accod. delle Scienze di Bologna,' 1866. 

+ Some yean ago (see ' DiseaMs of Women ') 1 propoied to subrtitnte the 
term "ectopic gegltiUoa" lai " extra -uteriae gestation" na being at once 
more conprehenBivc unil accurate. For exuuple, gestation in tbc uterine 
wuU, tbe Bo-caUed " interstitial " foriB, eamiot ia itrictneis be called " exlra- 
" but it is 



ON THE BO-CALLED " UIS8ED liBODB," 



95 



I 
I 



definite iniormatioii from this source. Intelligent attention 
directed to the subject could hardly fail to yield valuable 
facts. A singular example came under my knowledge. 
A gentleman who indulged a passion for breeding had a 
cow which had "missed her labour." Mr. Hawkin, 
surgeoHj then practising at Reigate, suggested that my 
hydrostatic bags might be applied to the benefit of the 
disappointed mother and her owner. A modification 
adapted to the pnrpose was contrived by the Messrs. 
Weiss, and a compressed dead foetus of about full 
development was extracted. But the cow did not, I 
undorstand, ever conceive afterwards. 

C. G. Carus, in elaborate memoirs,* supported the 
hypothesis of prolonged uterine gestation in woman, as 
well as in the lower animals. Bat his arguments can 
hardly stand agaiust a critical examination of his facts. 

McClintock, in his ' Purthor Observation on Missed 
Labonra,'t publishes some interesting histories. I will 
not lengthen this paper by reciting them, I will 
merely observe that they appear to be instances of the 
prolonged retention of a ftetus that had died before term. 

There are two very interesting specimens in the 
Mnseum of St, Bartholomew's Hospital. The first is No. 
3067, new catalogue, described as follows; — "The uterus 
of a sheep, containing a retained foitus, dried up and 
shrivelling. The ewe when killed stated to be in good 
condition. She had not brought forth the preceding 
season, sis months before, and it was supposed she had 
warped her lamb." This also is Ju ail probabibty an 
instance of retention of a foetus dead before term. 

The other case, No. 306&, new catalogue, was presented 
by Dr. Matthews Dnncan. It is thus described : — 
" Lithopeedion Calf, from the Earl of Southesk's ' Esme- 
■ " Znr Lebra von SchwangerKbRll und Oibort. ph;a. pathol. und then- 
pent. AbhsiidJiiiigcD mit beionderei Hinaiclit oof Vergteicbende Beobaob- 
tangen at) deo Tbienii," 1322. "Vou id luge danemdea SchirangcT- 
•ehafUn in der OebuTaatt«i a. von dcr Tenebuag der Frocht dorch din 
Utenu," 1624. 
t * Dnblin QturUrl; loanal of Medicine,' 1864. 



I 



96 ON THE SO-CALLED " MIS81D LABOUR." 

ralda.' She was served July 7thj 1865, had rinderpest in 
December of the same year. Being supposed to bare 
become sterile, she was fattened, and this process led to 
Blow expulsion of the calf, which was completed in October, 
1867j withont anything like labour ," 

In this case also the foetus probably perished before the 
natural term of gestation. Most likely it died under the 
influence of the rinderpest which attacked the mother 
about six months after conception. Dr. Duncan informs 
me that the cow was never again put to the bull, so that 
the interesting question as to the possibility of recoTery 
of fertility was not tested. 

The term " lithopEedion calf" seems open to objection. 
Examination of the specimen does not reveal evidence of 
the calcareous change which is the essential characteristic 
of the " lithopeedion." It is desirable to limit the term 
to cases in which this change has taken place. The 
specimen in question forms no exception to Cruveilhier'a 
proposition that petrified fcetuses are never found in the 
uterus. 

For the present, then, I am inclined to the opinion 
that the history of " missed labour " in the ewo and cow 
will be found to coincide very closely with what we know 
precisely of the history in woman, that is, that the cases 
of presumed labour of a living fostus at term are really 
cases of retention of a foetas dead before term. 

McClintock, in his ' Further Observations ' already 
cited, brings forward other cases reported to him. The 
details of one — that of Dr. Burden — are too meagre to 
form the basis of precise conclusions. The next case — 
that of Dr. Carson — is peculiar. " A woman came to the 
Anglesea Lying-in Hospital in the first stage of labour 
with her first child, at the completion of the ninth month. 
(In this state she was violently attacked by her drunken 
husband.) She complained of being injured in the abdo- 
minal region j her pains ctased, and the infant no longer 
exhibited any signs of life. Sho remained a few days in 
the house, and then went home. She returned in two 



ON THE SO-CALLKD " MIS 



97 



I 



■ cbi 

L 



months in stroug labour. The smL'll ui the air which 
escaped from the vagina was most offensive. Fifty-three 
hours later she was delivered by forceps of a decompoaed 
child. This was so blown up with air as to increase the 
size of the body to an enormous extent, which increased 
size had rendered the labour so tedious." 

May we conjecture that the violence inflicted killed the 
child and paralysed the uterus by the direct injury, and, 
secondarily, through shock upon the spinal cord ? Assum- 
ing this, we may understand that the normal vascular and 
nervous tension attending live gestation boing at an end the 
nterus might remain quiescent until, under the recurrence 
of the ovarian and menstrual nisus two months later, 
sufficient vascular and nervous tension were reproduced to 
eSbct the expulsion of the dead fcetns. 

If we adopt this view, the case falls within the same 
law us that which governs the ordinary cases of retention 
of a dead fcDtna, and this would not be a true case of 
missed labour, McClintock suggests that we might 
regard it as an example of prolonged or seroima gestation, 
but I prefer the view which I have indicated. 

McClintock's third case — that of Dr. John Brown — 
presents the following history : — A woman, aged thirty, 
became pregnant in April. In August, after carrying a 
load, she felt unwell, and next day had severe haemorrhage. 
In November she had severe uterine pains, and fcetal 
bones passed and others were extracted. No constitu- 
tional disturbance attended. She got well, and conceived 
again in the following April or May. 

This is a not very uncommon case of retention for some 
months of a foetus dying at a pneviable stage of intra- 
uterine life. 

Two other cases referred to by McClintock do not 
carry the evidence in favour of true missed labour any 
further. 

However just, then, may be the conclusions of Stoltz 
and Miiller iu negation of tbo prolonged retention of a 
child alive at term in utero, I submit that my case 

VOL. xxiu. 7 



98 ON THE SO-CALLKD " MISSED LAflOUR.' 

supplies almost irresistible evidence that the negation 
cannot be made to include cases of prolonged retention 
of a fcetus which had died in uiero before term, and also 
that the case of Drs. Hall Davia and Halley* cannot be 
rejected in the way that Miiller insists. In this case the 
removal of the ftetua was effected partly by spontaneona 
process extending over many months, and completed by 
operation after artificial jiilatation of the cervix uteri. 
Dr. Hall Davis is clear that he extracted portions of the 
foatua from the uterine cavity. The patient recovered. 
I have, at the opening part of this paper, expressed my 
opinion that Dr. McClintook'e caao also does not fall 
under the condemnation of Dr. Mailer's criticism. 

Of my own case I am entitled to speak with confidence. 
The history of the pregnancy and the degree of develop- 
ment which the bones had attained, make it clear that 
the foetus had lived until at least the seventh month, bo 
that the period of retention ended only by operatire 
intervention, lasted six if not seven months from the date of 
the death of the fcetus, and fifteen or sixteen months from 
the date of conception. Then comes the fundamental qnea- 
tion : Was the fcetua retained in utero ? Was it truly a 
uterine gestation ? Now, howsoever defective the evidence 
may be as to uterine pregnancy in Hall Davis's and 
McClintock's and other cases, I submit that in mine the 
evidence upon this point was as strong as evidence not 
completed by autopsy can be. The perfect and prompt 
recovery after the removal of the fcetus and placenta ie 
in itself a strong presumption that the fcetus was i-emovod 
from the uterus and not from an extra-uterine cyst. 
During the repeated manipulations necessary for exami- 
nation and operation, I had on several occasions a great 
part of one hand in a cavity continuous with the cervix 
uteri, and I felt the parts of this hand through a thiok 
dense wall, in no sensible respect differing from the 
characters of uterine wall, by the other hand applied to 
the abdomen. This observation was repeated and con- 
" ' Qbitetricsl TrHnsacttona,' vol ii. 




firmcil by Dr. Fancoort Barnes, who aasisted me, 
after evacuation, confirmatory evidence supplied all 
that seemed to be wanting. Repeatedly I introdaced a 
uterine tube to the fundus of the cavity to wash it out. 
It was a well-defined cavity with thick walls. More than 
this ; day by day I measured the cavity by the sound, 
aided by external palpation, and ascertained that it 
shrunk gradually and regularly as the uterus does after 
it is emptied, until at laat, before four months had 
expired, the uterus, as I now feel entitled to call it, had 
recovered its normal dimensions and other characters. 
To my mind, even a poat-iuortem examination could 
hardly have made the case clearer. 

To Bum up tho conclusiona which the actnai state of 
knowledge seems to justify, I would submit the following 
propositioiiB : 

1. That the prolonged retention of a fontus alive at 
term in uiero is not yet established by authentic facts ; 
and that consequently missed labour, if understood to mean 
the retention of a foatus in utero which had been alive 
at term, a distinct parturient effort being then mauifesbed 
and passing off, is also not yet established by anthentic 
facts. 

2. That a fcetus dying at a prseviable age in utero may 
be retained until the full term of gestation. 

3. That the case related in this paper afforda strong 
presumption, if not absolnte proof, that a footus dying at 
a viable age i" nlero may be retained for an indefinite 
time ; and that in this nense " missed labour " may be 
admitted. 

i. Iliat the clinical histories of tho cases known are 
not discordant with the following physiological theory : — 
When a living child is in utero, the natural high vascular 
and nervous tension accumulating and reaching its highest 
point at the ordinary term of gestation, labour almost 
infallibly takes place under the irritation of the tentli 
menstrual process ; and when the fojtus perishes before 
this period, that is, before the pbyaiological 



I 



100 ON THE SO-CALLED " UISSBD LAHOtlR." 

and vascular tension has reached its highest point, the 
nervous centres and the uterus may resist the menstrnal 
stimulus, remain quiescent, and thus the dead fcetus may 
be retained. The uterus thus comes to resemble in its 
behaviour an extra-uterine gestation cyst. 

Mr. Spehceb Wellb asked Dr. Barnes nhether his moat 
interesting case might not be explained on the aasiunption that 
the pregnancy was neither intra- nor Mtra-uterine strictly, but 
that form between the two, called by some interstitial or mural, 
in which the ovum is arrested just where the canal of the Fallo- 
pian tube passes through the wall of the uterus. He remem- 
bered that some attention had been ^ven to this suggestion at 
the bedside of l>r. Barnes' patient ; and he (Mr. Wells) thought 
that the subsequent history was quite consistent with this view. 
It was strengthened by a case he aaw last year at St. Leonards 
with Dr. Penhall. A lady, who beUeved she was in the fifth 
mouth of pregnancy, was reduced to a state of extreme danger 
by constant pain and vomiting. Eminent men had said she 
could not be pregnant, because the cervical canal admitted the 
&iger, and the sound could be moved freely to a depth of nearly 
five inches in the uterine cavity. Absence of bleeding and dis- 
chai^e negatived the fear of malignant disease, and the enlarge- 
ment was so clearly in the uterine wall that Mr. Wells and Dr. 
Penhall agreed in the diagnosis of mural pregnancy, and in 
treatment by ergot. Dr. Penhall injected ergotine into the sub- 
stance of the cervix uteri ; severe pains followed and the expul- 
sion of the fcetus, with complete recovery. 

Dr. BoPEB remarked tbtit a reasonable explanation of these 
so-called caseB of miased labour, ie to be given from a point of 
view hitherto unnoted. Moat of these recorded cases, he believed, 
were neither strictly uterine nor extra-uterine pregnancies when 
they came under notice. Originally they were uterine gestations, 
which during their course became partially or wholly extra-uterine 
in consequence of a degree of rupture of the uterus from external 
violence or injury of some kind, or from a spontaneous giving 
way of the uterine wall through degeneration of the uterine 
structure. It is not alleged that this rupture occurred to an 
extent as to allow the ftetus entirely to escape from the uterus, 
but to such a degree that ultimately a cyst was formed outside 
the uterus, the fcetus thus partly occupying the uterine cavity as 
well as the cavity of the cyst. The first symptoms observed 
were those of pain ; in every case the pains of Zoiowr were equi- 
vocal, and the commencement of these pains was coincident with 
some accident or external injury more or less severe. The fcetus 
at this time ceased to give signs of life and the pains subsid»d ; 



OS TUB 30-C 



" Hiaa^D LABODI 



101 



I 



then followed the history common to all — fetid discharge, putri- 
Iage,aQd bones. In every case in which it post-mortem eiajnina- 
tion has been made there has been found an aperture in the 
uterine wall connecting the cavities of the uterus and the cyst, 
the aperture seeming to represent the original rent or weak 
point which had pven way at the time when the first pains were 
observed. There are two facts in the clinical histories of well- 
known lacerations of the uterus in severe labours, which seem to 
correspond to those in so-called missed labour, n?,. the sudden 
cessation of pains and the speedy death of the fcetus. The 

fiains of so-called missed labour are not to be regarded as true 
abour pains, but as resulting from some lesion of the uterine 
wall. The histories of the cases which have recovered are pre- 
cisely like those in which a cyst outside the uterine wall has been 
found on post-mortem examination. In each case the fcetal 
bones have been detected in the uterine cavity, and have been 
wholly or partially discharged or removed through the os uteri. 
In the few cases which have ended in recovery it must have been 
very difScuU to search the uterine cavity so accurately as to 
determine with certainty the absence of a cyst. The trismic 
condition of the os uteri in these cases is interesting as illus- 
trating uterine polarity. The body of the utertts being injured 
its ftmdal polarity is arrested while cervical polarity remains in 
full force, hence the long retention of the dead foetus in utero. 
I am glad of the op|>ortunity of referring to uterine polarity, 
because there is no mention of it in English obstetric literature. 
Wo are indebtinl to Dr. Champneys for bringing this important 
subject to light, in an excellent article (' Obstetrical Journal of 
Qreat Britain and Ireland,' January, 18S0) translated from Beil, 
with valuable remarks of his own. 

Dr. Gbevis, as corroborative of the feasibility of Mr. Wells' 
suggestion on Dr. Barnes' case, mentioned a case of extra- 
utenne pregnancy be had watched in consultation with a 
medical friend, in which very unexpectedly at about the fifth 
month delivery occurred per viae naturales, and, on introducing 
his hand into the uterus to remove the placenta, the gentleman 
in attendance found a distinct cavity or pouch towards the left 
angle of the fundus, in which evidently the ftetus had lodged 
prior to its passage through the uterus. Dr. Gervis also referred 
to cases having an alliance with cases of " missed labour," in 
which, at the time when delivery was due, a few ineffective pains 
alone occurred, and the actual delivery did not take place until 
three or four weeks later. Dr. Gtervis gave particulars of one 
typical case of the kind in which this attempt at labour at the 
end of nine months occurred in successive pregnancies, with the 
result that a month further on instrumental aid was necessary in 
each instance, and the child born dead. At her fifth confine- 
ment the efi'orts of nature at the time calculated to be the proper 



102 ON THl 80-CALLBD ''XISSSD LABOUB.'^ 

limit of gestation, were supplemented by the means usually 
adopted to proToke and accelerate labour, and the result was 
the birth of a living and healthy child. At her sixth confine- 
ment, when matters were again *' left to nature," the same pro- 
tracted gestation occurred, with the result of a very large child 
which died in the birth, the labour being instrumental and 
extremely difficult. 



APRIL 6th, 1881. 

J. Matthewb DfJNCAN, M.D,, F.R.S. Ed., President, in tlie 
Chair. 

PreBent.^-45 Fellows and 13 visitors. 

Books were presented by Dr. H. W. Aeland, Dr. 
AJlchin, Mr. W. N. Cattlin, Dr. Hall Davis, Dr. E. W. 
Jenbs, Dr. H. R. Simpson, Dr. Heywood Smith, and 
Prof. Slaviansky, tho American Medical Association, and 
the "Soci6t6 des Sciences M^dicales de Lyon." 

William Gandy, M.a.C.S. (Gipsy Hill), and William 
Henry NethercUft, M.R.C.S., were admitted Fellows of 
the Society, and George Albert Farrer, M.R.C.S. 
(Brigfaouse, Torkabire) was declared admitted. 

The following gentlemen were proposed for election : — 
Thomas Hopcroft, M.R.C.S. (Dorking) ; James Henry 
Jeffcoat, M.R.C.S. (Chatham); Joseph Johnson, M.D. ; 
George Town Penny, B.A., M.E.C.S.; Phineas Barrett 
Tutbill, M.D. (Chatham) ; Jnlian Willis, M.R.C.P. Ed. ; 
and George Finch Jenninga Worthington, L.K.Q.C.P. 
Ireland (Sidonp). 



DERMOID CYST. 



Me. Knowslbt Thornton showed a very curions case of 
dermoid cyst o£ the left ovary, which had been entirely 
twisted off from its pedicle aiid had become attached by 
a new pedicle to the right side of the omentEm. The 
patient first came under his care seven, years ago, and then 
had a doubtful abdominal tumour, and as it was causing 
her no great inconvenience she was advised to leave it 
alone. She had since had four children, and during the 
last pregnancy the tumour gave her so much pain that 
the question of its immediate removal was raised, but after 
consultation with Mr. Spencer Wells, Mr, Thornton 
advised her to wait till after the birth of the child. She 
suffered great pain in and around the tumour at each 
month up to the birth of the child, but went the full time 
and had an easy labour. 

Mr. Thornton performed ovariotomy on April 2nd and 
removed the tumour, together with a cystic tube, and the 
remains of the twisted pedicle on the left side and a cystit; 
right ovary. The patient is now convalescent. 

The case presents so many features of interest that it 
will be fully published, bub Mr. Thornton thought it well 
to show the specimen while fresh to the Fellows of the 
Society. 

Dr. Hetwood Smith some years ago had a case of ovariotomy 
aimilar to Mr. Thornton's, where there was no true ovarian 
pedicle, and where after he had separated an extensive omental 
ftdhosion the cyst was free. In that case the pedicle had become 
destroyed in some way, and the nourishment of the tumour had 
taken place through the vascular connection of the omentum, the 
blood-vessels of which were greatly enlarged for that purpose. 
He considered the length of time the cyst in Mr. Thornton's case 
had taken to grow to be due to a similar condition, where time 
had been occupied in the constriction and obUteration of the true 
pedicle and the subsequent formation of the new vascular con- 
nection with the omentum. 



MICROSCOPIC SECTIONS OF 
OVARIAN CYST. 



Exhibited by Alban Dokan, F.R.C.S. 

The sections are from a dermoid ovarian cyst removed 
by Mr, Thornton from a woman, aged 31. It contained 
pill-like pellets of fatty matter, of a kind already observed 
and accounted for by Rokitansky, Routh, and other 
authorities. Small secondary cysts projected from the 
inner wall which, over these cysts, appeared to consist of 
patches of true skin, with hair and firm bodies, apparently 
the germs of teeth ; these bodies, however, proved to be 
cartilage. Sections of this cutaneous tissue were made 
by Dr. Vincent Harris, of St. Bartholomew's Hospital, 
and are exhibited this evening. 

One section shows a true epidermic surface, with large 
hftir follicles and well-formed sebaceous glands below. 
In others the structures found in normal subcutaneous 
connective tissue are seen, such as large plain muscular 
fibre cells. The tooth-like structures are simple masses 
of hyaline cartilage without any dental elements. The 
most interesting feature is the presence of well-formed 
muoous membrane in certain long nan-ow cavities in the 
subcutaneous tissue. This membrane is lined with per- 
fect columnar epithelinm, and bears numerous involutions, 
mostly deeper, at least, than Lieberkuhn's crypts, and 
some resembling pharyngeal glands. Near one of these 
gland-like structures a direct gradual transition from 
squamous to columnar epithelium can be observed. The 
squamous layer is very deeply stratified, as in thick 
epidermis, and has a distinct Malpighian layer not deeply 
pigmented. An abrupt notch separates it from a some- 
what deeper layCr of columnar epithelium, which ia set on 
very distinct basement membrane, below which ia 
lymphoid tissue. This change from epidermic to mucoaa 



^L a very 
^^1 lymphoi 



106 



9ECnOKS OF A DEBKOIS CTST. 



membranG is very remarkable, the more so since the 
columnar layer bears a strong resemblance to that which 
lines the intestines and stomach, which layer is derired 
from the hypoblast. Hence it would appear that a 
dermoid cyst may contain elements, derived in a aonnEd 
ovum from all three layers of the blastoderm. This is an 
important fact, although it does not decide whether 
dermoid cysts be produced by fcetal inclnsion aa a more 
or loss direct result of impregnation, or by a formative 
power which the ovary can exercise without impregnation. 
On the inclnsion theory one would expect to find elements 
from u!l the layers of the blastoderm ; on the other hand, 
if the ovary can, of itsolf, grow epidermic structures, there 
in no opidonco why it should not also produce elements 
normally growing from the hypoblast, for this innermost 
layer JN no more a special product of impregnation than 
are tho tipiblast and roesoblast. Lastly, it must not be 
fwrgotton that, as suggested by Mr. Thornton, the 
columnar opithelium in this section much resembles the 
epithelial lining of ordinary ovarian oyats'that do not bear 
ilcrinoiil (ilcmonts. 



Dr. OuAHi'KBva aaid that the fact that tbo pbairngeal glands 
art! liiii'il with uulumuar epithelium (the pharynx itself being 
iloTiiliip*nl from oil involution of the epiblast) is sufficient to show 
tliat iwihitimur epithelium is not characteristic of hypohlaatic 

111 rqily to Dr. Champneys, Mr. Dokah admitted that, apart 
(mm IliiHiry, it was not siirprising to find all varieties of epi- 
tliolium in cavitioa within ilormoid cysts. It seems reasonable 
lo niganl tho ovarian tinsuc, whence dermoid structures arise, 
rattler on Mumu undifferontiatcd kind of blastoderm than as a 
blaatodurin divided into throe layers, all of different formative 
jHtworH, an Hix^u after impregnation. 



I 
I 



CASE OF EXTREME ARREST OF DEVELOPMENT 
OF THE GENITO-URINARY TRACT IN A 
FEMALE FCETUS. 

By Alban Doean, F.R.C.S. 

A HiiruTB accotmt of the disBection of this foetuB will 
be fouiKi in the ' Journal of Anatomy and Physiology,' 
vol. XV, p. 226, with diagrams. The specimen has, 
however, Dover been exhibited, and as it has as yet only 
been inspected by two or three persons besides myself, I 
thought it advisable to show it to the members of the 
Obstetrical Society, and briefly to recapitulate its pecu- 
liarities. Whilst in the two specimens exhibited by me a 
year ago {' Trans. Obstet. Soc,,' vol. xxii, p. 79) it was 
but the completion of the development of the genito- 
urinary organs that was arrested, in this case their for- 
mation has been checked and distorted from the very 
commencement, and the uterine elements are absolutely 
unsymmetrica!. 

Briefly, I may state the following facts concerning the 
fcetus. Its mother was a healthy married woman, under 
the care of Mr, Ritchie Norton, of Tottenham, who has 
presented the specimen to the museum of the College of 
Surgeons. It wan bom at the soventh month, and breathed 
for a quarter of an hour, the heart continuing to beat for 
half an hour after respiratory movements had ceased. 
There was complete ectopia of the abdominal viscera, 
club-foot, lumbar spina bifida and great spinal distortion, 
bat all was normal above the abdomen. 

Separated from the gap through which the liver and 
stomach protruded is (for this part is preserved, the upper 
portion of the body being rejected) a flat space distinct 
from the abdominal cavity, but not covered in by epidermis. 
The skin met at the nmbilicas, and in this way separated 
the great gap from the flat space below. On this 



108 AHEBBTKD DBTIIOPMENT. 

space may be seen the bladder, consisting of two lobes, 
perfectly distinct, and between them, superiorly, the 
intestine opens from above into a circular aperture which 
freely communicates with the blind end of the intestine 
below. The ureters are impervious behind and close to 
the flat space. The right half of the internal sexual 
organs consists of the Fallopian tube and a tubular, thick- 
walled half-uterns opening freely into the flat space close 
to the right half of the bladder, it is quite of the lower 
marsupial type ; the ovary is atrophied. The left half 
iuoludc'S a perfect ovary and a Fallopian tube with a well 
developed fimbriated extemity, but the uterus is converted 
into an impervious cord. Below the two half-bladders is 
a nipple-liko prominence on the flat space ; it is the upper 
opening of a canal which passes through the pelvis, com- 
municating with the surface by an orifice in the left thigh, 
bordered by a fleshy excrescence, apparently representing 
A labium. This canal appears to be a monstrous over- 
grown urethra, there being no trace of any ano-vaginal 
involution of integument in the perineal region, still, from 
any point of view, its natnre is very obscure, and I doubt 
whether it bo the true homologne of any normal structure 
but possibly a confusion of several elements. The absolute 
want of symmetry in the internal organs is decidedly the 
most interesting feature in this case, and not the less 
interesting in being so distinctly capable of demonstra- 
tion. 

Dr. C'hampnbys said that dilatation ot the ureters is the usual 
couditiou in extroversion of the bladder, even where there is no 
structural impediment to the ureters. Such dilatation is more 
usual when the ureters open into the bladder than when they 
open eUewbere, e.g. vagina, rectum, &c. 

In reply to Dr. Boper, Mr. Doran stated that the ureters were 
dilated aWvo the complete obliteration of their canal close 
bebiud the rudimentary bladder, so that they evidently had con- 
tained urine. 



109 

CALCULI EMBEDDED IN FEMALE URETHRA, 

The Pkesidknt showed several small oxalic acid calculi 
which had been removed from the wall of the female 
nrethra, in which they had become embedded. 



FALLOPIAN GESTATION. 

Dr. Godson showed the uterus and appendages of a 
woman, set. 25, who had died in the Dorking Workhouse 
Infirmary from internal haemorrhage, resulting from 
rupture of a tubal fcfitation. Mr. Hopcroft, who had Bent 
up the specimen, could give no history of the case further 
than that the patient was believed to be unmarried and 
was in a dying state when she applied for admission. 
At the autopsy, about two pints of blood were found 
within the peritoneum. The specimen showed old 
adhesions attaching omentum and other structures to the 
uterus, both Fallopian tubes were tortuous, dilated 
throughout, and sacculated at their fimbriated extremities ; 
the right tube at this end contained a ftetus of about six 
weeks' development enclosed in a fleshy mass, on the 
inner surface of which the villi of the chorion could be 
seen. Dr. Godson throw out the suggestion that tho 
woman might have had gonorrhcea extending upwards, 
giving rise to the adliesions and to the subsequent 
dilatation of the tubes. 



I 



ANTEFLEXED UTERUS. 

Db. Hayes exhibited an unteflexed uterus, removed 
from a young woman who was unmarried, and considered 
to be a virgin. The flexion was well marked, the angle 
of flexion being situated just above the internal os. 
A submucous fibroid tumour, tho size of a small marble, 
growing in the posterior wall in the convexity i^f the 
flexed portion. A flbrous polypus, the size of a flattened 
pes, grew from the posterior wall of the cervix. 



ON THE SO-CALLED "MISSED LABOUR/' WITH 
A CASE IN ILLUSTRATION. 

The adjourned debate on Dr. BarBee' paper was opened 
by Dr. Inkson, who related the case of a lady who, when 
about three months and a half advanced in pregnancy, 
took a journey of five days' duration, in the hottest season 
of the year, along the plains of India. The fatigue 
produced great exhaustion, and the pregnancy appeared 
to cease to progress from this time. Although she did 
not increase in size naenstruation did not recnr. About 
the time that labour should have taken place under 
ordinary conditions, she took a long ride on a restive 
horse ; the severe shaking caused expulsive uterine pains, 
and an oval mass containing a very small foetus came 
away. Dr. Inkson was of opinion that the intense heat 
and fatigue caused the death of the fcetns, which might 
have been retained for an indefinite period had not the 
patient subjected herself to such violent shaking. 

Dr. Ems remarked that in seconding the adjournment 
of the debate on Dr. Barnes' valuable paper npon *' Missed 
Labour," he {Dr. Edia) had done so more with a view of 
affording those who were anxious to speak an opportunity 
of doing so, than of contributing anything to the discus- 
sion himself. 

In looking up the literature of the subject there seemed 
to be much uncertainty as to what really conetitnted 
missed labour. Dr. McClintock applied the term to a 
class of cases of uterine pregnancy, in which, through 
failure of parturient action, the fcetus was retained for 
some indefinite period beyond the term of normal gestation. 
Such cases are among the very rarest in obstetric 
practice. 

Several instances have been recorded by different 
authors of protracted gestation or postponed parturition, 
where gestation had been prolonged a month or more 



ON TSK EO-CALI.En "MISSED LABOBR." Ill 

beyond the time expected, an attempt at labour having 
occurred at the proper time but not terminating in 
delivery. Simpson recorded cases of parturition 324, 
332, and even 330 days after the last appearance of the 
catamenia. 

Meigs, of Philadelphia, gives the details of one cane 
where the patient became pregnant in July, had spnriona 
labour-pains on April 10th, but the child was not bom 
until the 13th of September, the pregnancy having lasted 
fourteen months or 420 days. Dr. Atlee also records two 
instances where the pregnancy lasted nearly a twelve- 
month. What struck him (Dr. Edis) in perusiug the record 
of these cases was the doubt whether they were really in- 
stances of intra-nterine gestation. In many cases there 
seemed strong presumptive evidence that they were in- 
stances of extra-uterine gestation, the supposed cervix 
uteri being nothing more than the fistulous opening in 
tho vagina communicating with the cyst. 

Dr. Miiller, in an essay " Do la GroBsesse Uterine 
prolong^ indefinetnent," published so recently as 1878, 
collected no less than forty-five observations of supposed 
missed labour. He shows conclusively that many of 
these were cases of extra-uterine gestation, and after 
careful consideration of the facts, so far as they can be 
relied upon, he comes to the conclusion that " there does 
not exist an authentic observation of retention of the 
fcotus within the womb beyond the term of ordinary 
pregnancy." In this conclasion Dr. Edis fully agreed, 
unless Dr. Barnes' case might be regarded as an exception, 
but even this may have been partly interstitial and not an 
ordinary intra-uterine pregnancy. 

Wd con Id not consider cases where labour was 
obstracted by contraction of the pelvic brim, inordinate 

3 of tho ffetuB, or from cancer of the cervix uteri, &c., 
where labour came on at the normal term, as instances 
of missed labour. In some of these cases the uterus 
ruptured, the fcetus passed through the rent into the 
abdominal cavity, and, if the patient survived the shook, 





wbvch an incident 
tiiAt the imi 



:■' '""(/ III tbt 

"Inch it WM 

\'"vwl la be 

■' it'" iil.orii<i. If no 

. 111! IfioKii wliu Hair it 

'I tlltJ IircKiiaiicjr was 
illinr (iimo of oxtra- 
<i[iii|iiTiiil "iqijiurting 
uilUlo ouuBii of the 



„a»ei wt tai«« •«* • <iiiMi-inBitttruttl m»m. 'I'liy [wtioiit 
WM Mkm iBie f^a/ft Uoapital «ix monlli* aftvr the full 



ON THE SO-CiLLID " KISSBD LABOUB." 



113 



term of gestation^ at which a parturient effort had 
occurred. Extra-uteriae pregnancy was diagnosed, the 
BBC lying behind the uterus, which was pushed forward 
and upward, and occupying in part the pouch of Douglas. 
No menstruation had occurred since conception except 
Bome sanguineouB flow at the full term. One evening he 
received a naessage that the patient was in labour. He 
found rhythmical pains taking place, the bed surrounded 
with screens, and all preparations made to receive an 
infant. The vagina was relaxed and lubricated with 
abundant mncus, as in the early stage of labour, and 
there wos some dilatation even of the cervix. To make 
the diagnosis absolute a tent was used, but the uterus 
was found to be empty. Twenty-four hours later, the 
rhythmical pnins passed off, and menstruation came on, 
and lasted naturally for several days, after which the 
state of things became again quiescent. 



Dr. GroDSON called attention to a case which came under 
his observation at St. Bartholomew's Hospital, which 
formed the basis of a paper by Dr. Groenhalgh, " On 
Missed Labour," in the eighth volume of the ' Hospital 
Reports.' After pointing out some errors of detail which 
had crept into print, notably one which described the head 
of the foetus as of six months' instead of four and a half 
months' development. Dr. Godson proceeded to say that 
the case much resembled that related by Dr. Inkaon, not 
being one of iniitged labour — in. which the patient advances 
to her full period of pregnancy, or at all events to a time 
when the child becomes viable, and then the fcttus dying 
she goes to an indehnite time before it is expelled — but 
being one of iiiis»ed abortion, in which the foatus dies in 
the early months of pregnancy and the patient fails to 
abort, the embryo being retained to a remote period. 

Dr. HsrwooD Suith remarked on Dr. Godson's obser- 
vation that menstruation had not taken place in cotMequenee 
of the presence of the arrested foetus, that it was an 

VOL. XHIi. 8 




114 



OK THE BO-CALLED " HtSSBD LABOUK." 



L 



interesting qneatioQ why sach should be the case, as the 
fcetng ceasing to grow, and ao pregnancy proper ceasing, 
why did menatmation not occur ? for it was probably 
owing to its non-appearance that the 0711m was not thrown 
off. 

The Phbsident said that it was an important part of 
Dr. Barnes' work to have gone 076r most of tho cases of 
so-called missed labour, and to have satisfied himself that 
there was no good case sufficient to prove absolutely that 
a child might die-iJt utero at the full term of pregnancy 
and remain there for weeks or months after death. 
Authors of weight denied entirely the occurrence of pro- 
tracted gestation and of missed labour. For his own part 
he (Dr. Matthews Duncan) believed in their occurrence. 
The probability of their occurrence was much supported 
by tho facts that they occurred in the lower animals, and 
that missotl abortion and missed miscarriage occurred 
certainly in women. He (Dr. Duncan) did not think the 
occurrence of labour premonitions a necessary part of 
missed labour. In a ease which he had seen and published 
in his ' Clinical Lectures ' there were no phenomena of 
labour till tho evacuation of the uterus was undertaken 
artiiicially. In the best case of protracted gestation which 
he had seen and published, there was a beginning of 
labour at full term and labour came on spontaneously 
some weeks afterwards. Dr. Duncan thought it desirable 
that lithopfedion should be better defined. At present 
the term was often used as synonymous with mummified 
ttotus ; but there were difficulties in the matter, for 
lithopajdion never occurred, as petrifaction of a fibroid 
was seen. The calcification in lithoptedion affected the 
membranes, and only sometimes the adjacent parts of the 
flatus. The fcBtus did not become calcified through and 
through like a good uterine calculus. 

Dr. Babhis expressed his gratification with the aid 
extended by lo many speakers in elucidating the interest* 



[ THE SO-CALLEr " UI3SKD LABODE." 



115 



I 



I 



iug aud difficult questions be had introduced. Beferring 
to Mr. Spencer Wells' suggestion, that the case might 
have been one of intra-mural gestation, he could only say 
that it was a speculation and nothing more. There was 
DO evidence in support of it, whilst the evidence that the 
gestation was intra-uterine was very strong. It was not 
usually a wise proceeding to seek to substitute for a 
rational and probable hypothesis, one that was very 
improbable. The usual course of intra-mura! gestation 
was to end by a fcctal cataclysm at the second or third 
month, whilst uterine gestation usually ended in recovery, 
as Dr. Barnes' case did. This recovery, then, gave strong 
presumptive evidence in support of that given by fre- 
quent careful physical exploration to establish the con- 
clusion that the gestation was simply uterine. Nor could 
he admit that Dr. Gervis's caseB, which were of an ordinary 
kind, supplied any evidence against this conclusion. The 
theory of Dr. Roper, that in these cases the gestation was 
uterine and that under violouco rupture occurred, resulting 
in partial protrusion through the rent into a sac subse- 
quently formed, was especially ingenious. He would not 
absolutely exclude this speculation as applicable to some 
cases, but he could not see that it applied in the case 
before the Society. There was no evidence in support of 
it. It was another example of the proposal of a very 
improbable theory for one that was probable and in 
harmony with known facts. Nor could the theory of 
perverted polar action of the muscles of the uterus apply 
here. The proposition of Dr. Galabin, that the uterus was 
known by its rhythmical action, although generally true, 
could not be expected to apply here. After the death of 
the fcetus, the nervous and vascular tension of gestation 
having subsided, the walls of the uterus underwent gradual 
condensation, aud contractility, if not lost, was much 
impaired. Oldham had discussed the probability of 
rupture of the nterus in bis case, but had rejected it. 
He was probably right. Dr. Edis adopted the dictum of 
Mtiller, that there is no case of retention in ulero of a 



116 



OH THB BO-CALLBD " HISSED LABODTt. 



fcetns, dead or alire, beyond term, Dr. Barnes snbmitted 

that this was too absolute. There was nothing so dan- 
gerous as absolute doctrine in medicine. He always 
observed with respect the maxim he had learned early i 
his career at Paris from one of the most eminent Eurgeons 
of the day : " Ni jamais, ni toujours." He would not 
therefore negative Dr. Duncan's statement that protracted 
gestation and missed labour might occur. He should make 
a point of studying Dr. Duncan's cases. In the meantime 
be thought protracted gestation for an indefinite time 
required better proof than we possessed. 

It was extremely important to attach definite meanings 
to the terms we employed. What ha means by missed 
labour was the indefinite retention in uiero of a fcotns 
beyond the normal term ; and he drew the distinction 
between a foatus dying in uiero at a prae-viable age and 
one dying, as in his case, at a viable age. In this respect 
his case did not go pari passu with Dr. Greenhalgh's, 
which was otherwise very much in point. 

He t}iought the term " missed abortion " so frequently 
used a singularly unhappy one. It could not survive the 
ridicule thrown upon it by McClintock, who said that 
long labour taking place naturally at term might strictly 
be called a " missed abortion." The term used by Stoltz, 
"concealed or incomplete abortion," was muofa to be 
preferred. The foatus died and was retained, Abortion 
in all but expulsion had been effected. He could not 
agree with Dr. Duncan that the terms " lithopfedion " 
and "mummified foetus" were commonly used synony- 
mously. A stone-child should at least be stony, it 
could hardly be confounded with a mummified foetus. 
To preserve the distinction was the more important, 
because Cruveilhier had insisted that a true lithoptedion 
was never found in the uterus. He believed Cruveilhier's 
statement was still true. Whenever a lithopEedion, then, 
was found it might be concluded that it was extra-uterine. 



I 



A CASE OF DELrVERT THROUGH AN IMPER- 
FORATE VAGINA. 



By Heywood Smith, M.A., M.D. Oson., 
pBTBiciAM TO TBS HOeprrii. ?ob wokbk, AMI) TO THB RBrnss lyiHO-ur 



I 
1^ 



Cases of atresia raginse, where a uterns eziata, are happily 
rare, though several have been recorded and operated 
upon; but caBes of congenital im perforation coincident 
with pregnancy are extremely rare, in fact, I have only 
been able to find records of two previous to the case I 
am about to narrate, viz. one in Paris, mentioned by 
Cazeaus, and one in New Tork, by Isaac Taylor. 

Cases of atresia also occur accidentally, i. e. as the 
result of cicatrisation following a previous labour, but 
these belong to a separate category. 

A little before midnight on the 15th of April, 1880, I 
was summoned to the British Lying-in Hospital to see a 
case that had just been admitted, the patient haying been 
in labour thirty hours. 

S. T — , fet. 31, married ten years, pregnant for the 
first time, was seen on the previous evening, April 14th, 
by Mr. Edwards, partner to Dr. Andrews, of Oakley 
Square. On examination, he was able to pass his fiuger 
only one iucb and a half into the vagina, further progress 
being arrested by a membrane, of the thickness of the 
vaginal wall, which appeared stretched over and inter- 
vening between tlio finger, and what appeared to be the 
head of the child. The only wide opening he found was 
the patent urethra. Being naturally puzzled, he sent for his 
partner. Dr. Andrews, who, without any difficulty, passing 
his finger into the very wide urethra, thought it waa the 
opening os uteri, and, giving the patient a sedative, 
counselled waiting till the morning. The next morning 
Mr. Edwards was sent for again, the woman being in 
strong labour, and found matters in statu juo. His 



118 



DILIVEEY THEOnOH AN IMPBEPORATE VAQIHA, 



^^H natural uneaBmeBS was modified — (1) becanee as the woman 

^^M had been impregnated he considered the labour ought to 

^^M terminate naturally, and (2) as Dr. Andrews had stated 

^^M that he felt the open os, he thought that time was all that 

^^M was needed; and he accounted for the abnormal cordition 

^^M by the sapposition that the child's head had forced the 

^^M posterior segment of the uterus downwards and backwards, 

^^M and so tilted the os forwards underneath the pubes. 

^^M Later in the day a more careful examination and inspec- 

^^M tion of the parts were made, when it was found that the 

^^B wide opening was indeed none other than the orifice of the 

^^M urethra widely patent. 

^^M At last, it haying been placed beyond all donbt that 

^^M there existed a very serious abnormality, Dr. Aveling waa 

^^M sent for in consultation, and the patient was examined 

^^M under complete amestbesia. Dr. Aveling then found that 

^^M the vagina was a complete cul-de-siic ; he could feel the 

^^M uterus through the vaginal wall, and made out the os 

^H uteri to be dilated to the size of half-a-crown. As the 
patient lived in a small room. Dr. Aveling recommended 
her to be removed at once to the British Lying-in 

^^ Hospital, where she was taken and admitted, still partly 

^^L under the influence of chloroform. 

^^M In his letter accompanying the case. Dr. Andrews 

^^M related the above facts, stating Dr. Aveling's opinion that 

^^M the case would need an opemtion before delivery could 

^^H take place ; that the case was quite unique, neither of 

^^1 them having met with a similar one. 

^^1 On my arrival at the hospital, and proceeding to exa- 

^^1 mine the patient, I passed my finger at once into the 

^^H urethra quite easily; it would almost have admitted two 

^^M fingers, so that I was not in the least surprised to learn 

^^1 that it had at first been mistaken for the vagina. How- 

^^1 ever, on more c^n-eEul examination I found that the vagina 

^^1 was only one luch and a half long, that it was fairly 

^^1 roomy as far as it went, and that the roof was of the 

^^1 ordinary thickness of the vaginal wall. This vaginal roof 

^^H was lax, and as the child's head waa arrested at the brim, 



DBLrTBBT THROUGH Atf IMPBRFOEATB VAOIHA, 119 

and BO was not pressing down on this membrane, it could 
be pushed upwards antil the child's head was reached, 
when it was found that the head was uncovered by any 
uterine tissue, that, in fact, the os uteri was Fully dilated, 
and the bones of the fnetal head were felt to be already 
overlapping. 

The vaginal wall was absolutely free from any cicatri- 
cial tissue whatever, neither was there any constricting 
band. A most careful examination failed to detect the 
slightest orifice, or, indeed, any irregularity or depression 
that would load to the idea of the previous existence of 
any canal. The case showed that there was a dis- 
tinct flour of ordinary vaginal tissue separating the 
short lower passage of the vagina from an upper chamber 
into which the child's head was protinding. 

There being, therefore, no ontlet for the child, I pro- 
ceeded to operate as follows : — I picked up a portion 
of the vaginal roof with a pair of forceps, and cut right 
through its whole thickness with one cut of a pair of 
scissors, and iutrodacing my finger I came ai once on to 
the child's head. I then gradually introduced two other 
fingers, and proceeded to tear the opening thus made larger. 
There was some slight haemorrhage, but not much, and 
after a short time I was enabled to get the greater part of 

■ my hand through the opening in the vaginal roof. I 
then, as the woman had already been more than thirty-two 
hours in labour, put on the long forceps, and delivered her 
of a living female child. 

The woman recovered without any bad symptoms, and 
before she loft the hospital I examined hor and made the 

I following note : — Urethra patent enough to admit the 
finger two inches. Vagina natural to the point of the 
incision daring labour. At that point there is a slight 
constriction, with, on the right side, a small fiap, the 
remains of the congenital vaginal roof; just above this, 
on the right side, is a raised patch about three qnarters of 
an inch long by a third of aa inch broad, rather lighter 
in colour than the vaginal wall, feeling and looking a$ if 



130 



DIUTXBT THBOrOH UI IlfPEBFOBATE TIQINA. 



ft wn* A pfttcb of epithelioma ; the cervix ateri was 
BAtunl, and the os slightly patent. There was also a 
gaukll patch similar to that just described, and about the 
sue of a tIatteDed pea, on the inside of the right labium 
najus. The infant is well and the mother nnrsing it. 

Ejiamiaatioii in June. — At an inch and a half distance 
from the vaginal orifice a ridge rona all round the vagina, 
marking the position of the former vaginal floor. Above 
this mark the vagina appears fairly natural ; the con- 
stricting ridge admits two fingers barely. The lips of the 
cervix uteri not large, cervix not long ; the sound passes 
^jt inches. The flap before observed still exists. The 
patch on the vaginal wall has disappeared. 

Examinalion December 7fh. — Slight constriction of 
vagina at the site of the former vaginal roof, admitting 
a fair-sized speculum. There was a slight crack along 
the posterior left aspect of the constricted part of the 
vagina. Woman otherwise healthy. 

The history of the case is as follows : — Father and 
luother healthy. A sister died in her first confinement, 
L-ause not known ; child living. Menstruation commenced 
(Bt, 13, and was regular j flow free, at times accompanied 
with clots; pain at those times severe, especially at the 
commouoement, and " confined to the passage through 
which it oamo." Her mother, now dead, told the husband 
that the patient was not made right and would never 
have any children, and that if she ever did become 
pregnant she thought she would not get over it. This 
oviduuco is very important, as it proves that the abnormality 
waa oougenital. Moreover, the mother was said to have 
bot>n a trained nurse, and bo her opinion must be allowed 
b certain weight. 

Attor her man-iago, ten years ago, the catamenia con- 
tinued regular and painful, the flow being ushered in 
with " abarp pains." 

About a year and a half ago she suffered so much from 
"whitvit" botwoeu the periods, that she attended as an 
out-patient at the Middlesex Hospital. 



DELITEBY THROUGH AN IHFEBFD&&TE VAGIHA. 



121 



I 



Through tte kindness of Dr. Edie, I have been favoured 
with his notes of tho caae taken at the time. Ho wanted 
her to come as in-patient tor an operation, bat she would 
not consent. 

" S. T — , set. 30, married nine years. Catamenia 
regular, scanty, and painfnl. Complaining of thick 
yellow discharge, causing irritation in the groin. Pain 
in the left side. Bowels confined. No sense of taste or 
smell. Vaginal examination : on attempting to pass the 
finger per vaginam, the tip enters a cnt-de-sac, about one 
and a half to two inches long. No orifice of any kind 
coold be detected by tho sense of touch, nor Been on 
inspection ." 

This testimony from so experienced an observer is of 
special value, as it confirms the former history, makes no 
mention of the presence of any cicatrical tissue, and shows 
that there was no orifice that could possibly be detected 
even after a minute examinatiou. 

The husband stated that generally there was no 
difficulty in coitus, but sometimes it produced great pain, 
and it appeared that he entered a narrow pipe. I think 
this points conclusively to the fact that the urethra was 
used during intercourse, and fully accounts for its abnormal 
patency. 

The point of chief interest about the case is how did 
the woman become pregnant ? Was there a small 
pin-hole passage through the congenital vaginal roof with 
R valvular orifice that rendered it undetectable, or was 
there a commnnication between the bladder and the 
upper chamber of the vagina, through which the menstrual 
flow took place, and through which the semen obtained 
access to the uterus ? The other recorded cases, as tar as 
I have been enabled to discover, throw no light on this 
important question, but perhaps some Fellow of the 
Society may have met with some case illustrative of this 
point. 

I will now refer to one or two published cases that 
bear on this rare malformation. In vol. zii of oar 



1S2 



DSLrrBBT THKOtJOH AH IlfPBBKIBATE VAGINA. 



I 



L 



' Tr&as»otiou3,' p. 84, there is a paper by Dr. Ronth, " On 
fk Remarkable Caae of Absence of YagiDa, with retained 
Menses it Ut&ro and Fallopian Tubes." A patient, sat. 
M, was brought to him by Miss Garrett, December 18th, 
1869. " An examination locally, revealed an unnsnal state 
of things. . . . There was no vagina, but a sort of 
oeecum, certainly not longer than half an inch, i£ that. 
Superiorly waa the arethra, which was dilated so as to 
admit the little finger, into which a catheter introduced 
drew o£E the urine." In this case two features present 
themselves, similar to the case under discnssion, riz. the 
vaginal cul-de-sac and the abnormal patency of tha 
urethra ; the cause, however, of this patency in so youa^ 
a girl does not appear. 

In Cazeaux' ' Traite Thfiorique et Pratique de I'art dos 
Accouchement 9,' 7th edition, 5th part, chapter 5, on 
" Dea vices de conformation de la vulve et du vagin," p. 
600, there is a footnote relating a case of labour impeded 
by vaginal obstruction. 

The other case to which 1 will draw your attention is 
contained in a paper on " Atresia of the Vagina, Con- 
genital or Accidental, in the Pregnant or Non-Pregnant 
Female," by Dr. Isaac Taylor, of New York, published in 
the ' Transactions of the American Gyniecological Society,' 
vol. iv, p. 4. 

Dr. Taylor says: " Cases of congenital absence of the 
vagina aro rare ; cases of the same nature existing during 
pregnancy and involving two lives are more so." He 
then gives the notes of a case under the heading " Com- 
plete congenital atresia of the vagina ; pregnancy ; safe 
delivery j child living ; treated by the tearing process." 

The case, as narrated by Dr. Isaac Taylor, reads almost 
like a transcript of my own, nevertheless there are one or 
two points of difference that lead me to believe that the 
case 1 have brought before the Society is unique. In 
Dr. Taylor's case as labour progressed a slight depression 

the vaginal wall became perceptible to the finger, and 
advantage wu8 taken of this as marking the point where 



DILITIXT TBBOUOE AS tKPIBIOUTS VAOIKl. 



123 



the opening through the Taginal wall was subsequently 
made by aoratcbing with tbe finger-nail. Bat in my case 
no inequality of the vaginal sarface was discovered which 
could lead in the least degree to the supposition that any 
opening, even a valvular one, existed. True it was that 
the head being arrested at the brim there was no pressure 
from the presenting part of the child to help in any dila- 
tation ; but would not the gradual softening of the parts 
have led to the discovery of an opening, however small, 
if such had existed ? 

Again, in Dr. Taylor's case there was no necessity for 
any incision ; the depression referred to was bo thin that 
laceration was easily eilected with the finger-nail, whereas 
in my case tbe whole vaginal roof seemed to be of the 
same thickness as the ordinary vaginal wall, and the 
tisane cut through with the scissors was of considerable 
snb&tance. 

When Dr. Taylor examined his case two montha after 
her confinement, he fonnd two constrictions, one near the 
vulval orifice and another nearer to the ntema, whereas 
in my case there was only one constriction, and that an in- 
considerable one, at the site of the former vaginal roof. 

And again, in his case it appeared at a subsequent 
visit that the parts stiU tended to contract, whereas when 

II examined my case only last December the vagina 
remained fairly patent. 
There remains still the interesting question, that pro- 
bably cannot now be satisfactorily answered, namely, how 
did this woman become impregnated ? Did there eiist, 
though it was not discovered, a minute opening through 
the congenital vaginal roof ? Or, as it seems probable that 
connection took place by the urethra, was there an open- 
ing from the bladder into the superior chamber of the 
vagina f If such had existed it is quite possible that, 
after labour, during the natnral contraction and involution 
of the parts, no further need existing for its patency, it 
finally closed, 
At all events the case is one full of interest, and on 



124 DBLIVEET THROOOH AN lUPERFORATI! TAOIHA. 

account of its rarity I deemed it of sufficient importance 
to bring it before this Society. 

Dr. Bakneb obsetred that Oldham long ago had pointed oat 
that in some c&bc'b of absence of vagina the urethra was largely 
patent, and this without having served for sexual interconrses. 
It was not necesBary to postulate a fistulous communication 
through the bladder into the upper pouch of the vagina to account 
for impregnation, The spermatozoa would find their way as in 
well-known cases of intact hymen. There was no doubt a small 
aperture leading to the uterus at the time of coitus which hod 
Ijocome closed after impregnation. He had seen such a case 
where apparently complete closure had occurred from cicatricial 
contraction after sloughing. He had seen a considerable number 
of cases of absence of vagina. He bad successfully treated them 
by incising partly and by stretching. In one case pregnancy 
took place after operation, and the subject died suddenly in the 
third month. The gestation took place in a one-homed uterus, 
which burst. An example of a successful operation, fatal to the 
subject. But there was a greater mystery in Dr. Smith's case 
than that of the conception. It was that expressed in the title 
of his paper : " Delivery through an imperforate vagina." He 
was glad to hear that this was solved by perforating the vagina. 

Dr. BouTH said he thought there were steps in the observation 
of Dr. H, Smith's caao which could explain the impr^nation. 
Dr. Smith hod elated that this woman had been treated during 
her pregnancy for whites, with a good deal of local inflammation, 
in fivct a vaginitis. Then that at the upper port of the vaginal 
diaphrngni there was an indurated portion that looked Uke 
opithutinmn, but which was not so, because it subsequently dis- 
npiicari'il. Wliy should uot this induration have been tho 
n.>miiining lucatrix of an opening in a hymen situated in the upper 

Iiart, which allowed impregnation to occur prior to the vaginitis, 
tut wait afterwards closed by this infianmiation ? Theao 
iustaiiecN of iicrforiitiou by small pin-holes in vagina admitting 
llatus from tuo rectum, or urine from the bladder, often existed, 
and t"Ould not Iv detected by the closest observation, and very 
oonmionir oiilv Immiuhc oV>vious by injection of milk or coloured 
fluid, ^by sliould uot such an undetected small opening havo 
I'xiatwl hotv ivlso P 



A CASE OF mPBBFORATE VAGINA. 



By Peecy Bodlton, M.D., M.R.C.P. Load., 
phtsicus to ' 



I 



C. B — , set. 18, married, came to me on Sept. SOtli, 
1880, at the Samaritan HoBpibal ont-pationt department, 
complaining o£ "something being wrong with her." 

The catamenia always were accompanied by some pain j 
they lasted aboat three days, and were followed by " green 
waters " for several days after. 

On examination the vagina was fonnd to be a cul-de- 
sac, aboat an inch and a half deep, and no opening what* 
ever coutd be felt. 

The fact of menstmation made it evident that some 
outlet existed, and as the patient was intolerant of exami- 
nation I determined to put her under chloroform and 
ascertain the condition of things, if possible, as it was 
evident that if pregnancy should occur this abnormal 
vaginal condition would be a formidable complication. 

I took the patient into Dorset House, and Mr. Mere- 
dith administered methyline while I examined the vagina 
wilt a dilating speculum. Wlen on the stretch I found 
at either side of the vaginal terminus a small opening, 
through which I could pass a probe, which openings were 
not visible when the parts were not on the stretch. 
Through iheae the menstrual Boid escaped, and the " green 
water " was the result of its partial retention. 

It was impofisible to know what lay beyond the vaginal 
eul-de-sac, so I determined to dilate the openings with 
tangle, in order to ascertain precisely. I found — 

1. A normal uterus, not a doable one, as seemed possible. 

2. That the vagina was tripartite, an upper and a 
lower, the upper one being daplex, the partition extend- 
ing between the cervix uteri and the transverse vaginal 
septum. The longitudinal division was triangular in 
shape, ^e apex being towards the uterus nud base below. 



126 IMPERFORATE VAOINA. 

The two upper vaginal divisions were dilated Gomew'Bai 
by retained discharges, and I foand a small commimi cation 
close op to the uterine necb. 

This I have indicated in the accompanying drawing, the 
arrows showing the aitnations of the openings, which were 
patent only on cooBiderable vaginal distension, above by 




catamenial finid, below during connection, so that a preg- 
nancy might easily have resulted. 

Treatment. — It was only necessary to divide the central 
block to make a perfectly normal of this curiously congeni- 
tal abnormality. This I did by passing whipcord round 
by means of a sound with an eye at the extremity, which 
acted like a magnified aneurism needle. The ends of the 
whipcord I attached to an Soraseur, and the division was 
speedily accomplished without bleeding. 



IMPERFOEiTE TAOrNA. 127 

The after-treatment consiated in the wearing of a vul- 
canite vaginal ping for three weeks, when all being 
healed the patient returned home perfectly well. 

This case shows the value of dilating, when it is prac- 
ticable, before surgical interference, as it might have been 
a very dangerous proceeding to hare operated in any way 
without knowing what lay beyond the vaginal cul-de-sac 
in a case of congenital malformation. 

Had I cnt from without inwards there might have been 
troublesome bleeding, and with the cautery I felt that the 
cicatrix or subsequent contraction might be an impedi- 
ment in a future labour, while beyond the slight manipu- 
lation difiSculty of passing anytlung round this centre block, 
the plan which I adopted could scarcely be objected to. 

Dr. CoAMPNEYB said that a point of gireat interest in the case 
was the aaeociation of fleshy vaginal transTerse partition with a 
vaginal septum. He had seen several cases where a fleshy hymen 
waa perforated by two duct-like openings lying side by side, and 
in a case of extroversion of the bladder in a female child, which 
he published in ' St, Bartholomew's Hospital Eeporta ' vol. xiii, 
he expected from this appearance to find some want of fusion of 
the ducts of Muller, either as vagina septa or uterus septus. In 
that case no such condition existed, but ho had lately been shown 
a case by the President in which his guess was correct, the upper 
part of the vagina and the uterus being divided by a septum, 
similar duct-like holes beingipresent. He was disposed to regard 
fleshy hymen as a sign of disordered development, shown by the 
frequency of these duet-like openings to be closely akin to vagina 
septa and uterus septus. 

Dr. BocLTON expressed his conviction that in most, if not all, 
cases of apparently imperforate vagiua, where menstruation or 
pregnancy occurs, a pin-bole opening exists and may be found 
if diligently sought for. His own was very much a case in 
point, and he was glad it had been taken in conjunction with 
Dr. Heywood Smith's very int«reBting case, as he thought it 
offered the probable explanation of the pregnancy. 




MAY 4th, 1881. — 

J. Matthews Duncan, M.D., F.B.S. Edin., President, in 
the Chair. 

Present — 41 Fellows, and 5 visitors. 

Books were presented by Dr. J. M. Dolan, Dr. Lewis, 
Dr. Mason, Mr, Albert Napper, Dr. John Thorbum, and 
Dr. Van der Bosch. 

A cast of a fcetal head, showing the characteristic 
depression in the left temporal region, caused by the 
promontory of the eacrnm, was presented by Dr. George 
Koper. 

The following gentlemen were elected Fellows of the 
Society: — Thomas Hopcroft, M.B.C.S. (Dorking), James 
Henry JefEcoat, M.R.C.S. (Fort Pitt), Joseph Joknston, 
M.D., George Town Penny, M.A., M.R.C.S,, Phineas Bar- 
rett TathiU, M.D. (Chatham), Julian Willis, M.R.C.P. Ed., 
and George J. Jennings Worthiugton, L.K.Q.C.P.I. 
(Sidcup). 



PLACENTA FROM TRIPLETS. 

Db. Gaubin showed, for Dr. John Bassett, the placenta 
from a case of triplets. In this case the placenta when 
€xamined on its aterine surface presents the lobular 
appearance met with lu a single btrth, whilst on the foetal 

vol,, uuii. 9 



130 



ABHORUAL ATTACHMSNT OP PLiCKSTA, 



side are attached three timbilical cords and the remains 

of three seta of membranes ; on neither surface is there 
any distinct appearance of separation, such as is usual in 
multiple births. Was the Graafian follicle from which 
this conception resulted a compound one, with three yelks . 
and three germinal vesicles ? or were there three sepai-ate 
vesicles impregnated at the same time and deposited simnl- 
taneously on a common decidua ? It is well known that 
in ordinary twin births the placentte are separate bodies 
placed side by side, and, from the childi'en constantly 
differing in size, it is fair to infer that many of them are 
cases of superffBtation ; in a small minority of cases of 
twins there is a single placenta with two sets of mem- 
branes and two oords ; these belong to the same category 
as the specimen now exhibited. What is the answer to the 
qnestions hero stated to the Society ? The pregnancy was 
in every way a natural one, and advanced to nearly the f nil 
term without noticeable incident ; the children, all females, 
were of fair size, two are still living, the larger one died 
when three months old from an attack of peritonitis. 



ABNORMAL ATTACHMENT OF PLACENTA. 



Dr. Gaiabin also showed, for Dr. John Bassett, a fajtna j 
with the placenta adhering to the cerebral membranes. 
hi this case the base of the skull is imperfectly formed 
and the vault is absent ; the placenta is seen adhering to 
cerebral membranes ; no brain substance was developed ; 
the cerebral membranes contained some fluid, how much 1 
was not ascertained, as they were ruptured at the time of 
birth ; the placenta was previous. Nothing abnormal waa 
noted about the pregnancy until nearly the end of tha j 
eight month, when heemorrhage set in, this was not, how- 
ever, 80 severe as to lead to immediate interference. Oa 1 



leiter's TEMPEBATCKE reoclator. 131 

the tenth day after the hteniorrhage began labour came 
on apontaoeotialy, and, as the hemorrhage was severe, on 
the arrival of Mr. Draper, who was in attendance, he 
deemed it expedient to effect delivery by turning. The 
child was born alive, and respired imperfectly for about 
an hour; the patient made a satisfactory recovery, her 
health is believed to be good, and she has had four 
healthy preguanoiee previously. 



PESSAHIES OF ZYLONITE. 

Dr. Meadows showed pessaries made of the 
material zylonite, a compound of paper and nitro- 
glycerine. It was more clastic than vulcanite, and could 
be more completely softened for moulding by boiling 
water. 



LEITER'S TEMPERATUEE REGUIATOR. 

Dr. Godson showed a new apparatus for applying heat 
or cold to the surface of the body. It is known by the 
name of Leiter's temperature regulator, and consists of 
a coil of very pliable metallic tubing, which may be 
twisted into auy shape to adapt itself to different parts of 
the body. By means of rubber tubing attached to either 
end, one communicating with a vessel of water placed at 
a higher level, a continuous stream of hot or cold water 
can be made to circulate through it. Dr. Godson thought 
it would be valuable in post-partum hasmorrhage, as it 
could be made to grasp the uterus tightly under the hand 
or under a binder. 



FLESHY SUBSTANCE DISCHARGED FROM 
UTERUS. 

Dr. Clbvelahd exhibited ft cylindrical fleshy sobstance, 
about three inches long by three quarters of an inch in 
diameter, having an aperture or mouth with hps at one 
end that led to a channel, about the size of a quill, running 
its entire length. It had a i-emarkable resemblance to a 
nteruBj and was expelled with pain and slight hremor- 
rhage three days after the delivery of a seven months' 
child, which presented nothiug unusual. The lady, who 
had previously borne eight living children at term, stated 
that in her last two labours a similar substance to that 
exhibited, but rather larger, had been expelled on the 
third day after delivery. 

A committee, consisting of Dr. Galabin, Dr. John Williama, 
and Dr. Cleveland, was appointed to examine the specimen and 
report thereon. 



CASE OF PHLEGMASIA DOLENS WITH 
LYMPHATIC VARIS. 

By J. Matthbwb Duncan, M.D, 

I LAY the following case before the Society on account 
of its own interest, but still more with a view to contribu- 
ting something that may help ub towards a complete theory 
of the pathology of phlegmasia dolens. It is not mj object 
in the meantime to discuss fully this important matter, and 
it is merely to maintain the continuity of the Society's work 
that I recall to mind the elaborate and full consideration 
given to it in our ' Transactions ' in three papers by Tilbury 
Fos published therein. 

Thrombosis and inflamniation of veins, the most striking 
lesion observed, is not invariably present, a circumstance 
which, apart from other considerations, demonstrates its 



PHLE0UA.B1A D0LRN8 I 



1 LYMPHATIC VAEIS. 



13; 



insufficiency as a basis for the pathology of this diseaBe. 
The wide acceptance of this theory of phlegmasia dolena is 
not astonishing, for it had mnch to recommend it as a solu- 
tion of a difficult (and still unsolved) problem. Long before 
the times of Davis, the original propounder, and of Robert 
Lee, the supporter and improver of the theory of the 
venous origin of the disease, it had been suggested by 
various authors that the lymphatics were affected, either 
alone or along with the veins, and that the affection was 
inflammation, or obstruction, or both. Amidst a confusion 
of more or less conflicting pathological explanations, this 
lymphatic origin has always maintained a prominent place, 
and it is supported by Tilbury Fox. I, also, am disposed 
to support this hypothesis, that phlegmasia dolens is due 
to venous and lymphatic inflanamation and obstruction, and 
that of these two the lymphatic disease is the more im- 
portant, especially as being probably present in every 
case, while the venous disease is occasionally absent. 

Our knowledge of the anatomy, the physiology, and the 
pathology of the lymphatics is still comparatively limited ; 
and these remarks apply with such cogency to the subject 
under discussion as to command great modesty in the 
statement even of hypotheses as to the lymphatic theory 
of white leg. It is from this kind of view that the follow- 

Iing case has appeared to me important and worthy of 
record. It nari'ates, inter alia, a series of facts as to the 
lymphatics in a single case ; and " one fact is worth a 
cartload of arguments," especially when, as here, facts are 
in the highest degree rare. 
Although a well-marked example of white leg, the case 
did not occur in the puerperal state, but in the downward 
progress of advanced and characteristic carcinoma uteri. 
Its history embraces the latter part of an extensive and 
severe affection of the entire left lower limb, and the 
whole course of a slighter attack affecting, on the right side, 
the leg proper only. Shoreaided in St. Bartholomew's Hos- 
pital from November 17th to January 7th, when she went 
away regarding herself as in much improyed if pot iq 



134 



FELEOUASIA DOLEKS T 



I LTHFEATIC VABIX. 



fairly good health, considering the Berions diBease whiob 

remained. 

When ehe entered the hospital there were no remains of* 
the hard, tender and not pitting cedema of an earlier stage of 
wliite leg, though in some parts there was a near approach 
to these conditions. The whole left leg proper was tender 
and rodematoua and pitted on presaure, but was not ao 
soft and easily dented as an ordinary anasarca. Besides 
these two conditions of this lymphatic cedema there is a 
third, which was very marked in this case, namely, swelling 
without any tenderness and without any pitting on pressure. 
It affected the thigh, and wonld have escaped detection 
had there not been the healthy right thigh with which to 
make comparison. It is important in the description of 
cases to keep in mind these three varieties of lymphatic 
toderaa; and in regard to the- last kind, made out by 
comparison with a healthy limb, it is to be remarked that, 
if the other limb itself is also affected, this kind of swelling 
may remain undetected or at best only guessed at. 

When the lymphangiectatic patch of the left leg was first 
observed (see Plate I) on her admission to the hospital, the 
phlegmasia dolens was subsiding, and the distended lymph- 
atics were probably mnch less than they had been before her 
illness became so prolonged as to compel her to take refuge 
with us. The part visibly affected was the skin of the upper 
and outer anterior surface of the left thigh ; and it con- 
stituted an oval or triangular area, broader above- than 
below, and of such extent as might be nearly covered by 
the hand. There was no pain nor tenderness. The pro- 
jecting vessels, covered by epidermis, having a yellowish- 
white tint and pearly lustre, were seen and felt, and the 
prick of the small point of a knife allowed a large drop of 
limpid lymph to immediately exude. Two days after the 
pricking and for some days subsequently we thought we 
could feel the Ij luphatic vessel consolidated, presumably 
by thrombosis, above the prick, about half an inch, and 
from the prick to the junction of another anastomosing 
lymphatic. As the white leg diminished and disappeared 



I 
I 



DESCRIPTION OF PLATES I and II, 

Illustrating Dr. J. Matthews Duncan's Case of Phlegmasia 

Dolens with Lymphatic Yarix. 

PLA.TB I. — Fading lymphatic patch of left thigh, as seen several days after 
admission, and abont three weeks after the commencement of left phlegmasia 
dolens. 

Plate II. — Skin-crack patch of right thigh, as seen before attack of right 
phlegmasia dolens. 




.*i*!?'#«;|S^j 



PHLEGMASIA DOLENS WITH LYMPHATIC ^ 



135 



I 
I 



so did the lymphangiectasia, but the lymphatica, as marked 
by visible and not otherwise sensible, much contracted, 
pearly lines on the surface, remained till she left the 
hospital, and will probably persist daring life. 

As the disease was slowly disappearing from the left 
limb there began a similar affection of the right one; bnt 
the attack was not severe, the tenderness and swelling never 
considerable, and affecting only the leg proper, and it passed 
off with rapidity when compared with the left-side affec- 
tion. On the same part of the right thigh as was occupied 
by the lymphatic patch on the left there had been observed 
(and pictured) an oval patch of ordinary spindle-shaped, 
ribbon-like, skin-cracks, not silvery lines (see Plate II) ; 
bnt, now that phlegmasia dolens seized the limb, the skin 
cracks became obscured, and at last scarcely to be detected, 
the whole area of the cracks being occupied by a network 
of lymphatics exactly like what had been on the left side, 
the vessels being only less distended. As the phlegmasia 
diminished the lymphatic enlargement faded, hut the skin 
never lost the pearly lines mapping the course of the 
lymphatics, and never resumed the previous appearance of 
skin merely injnred by extensive skin cracks. When the 
woman left the hospital the special areas on both thighs 
were closely alike, the lymphatics being seen without 
being looked for, the skin cracks not easily seen but easily 
discovered in small parts when looked for. 

There can be no doubt that in this case both thighs 
were, before the coming of phlegmasia dolene, or originally, 
alike, having each a patch of skin cracks, which probably 
arose in connection with pregnancy. In both thighs the 
area of skin cracks became the area of varix of cutaneous 
lymphatics. In both thighs the lymphangiectaais was part 
of the phenomena of phlegmasia dolens. It seems highly 
probable that the mechanical weakening of the skin, as of 
a bandage, which should itself he uniformly strained and 
uniformly support subjacent parts, was a predisposing cauiie 
of the lymphangiectasia in their special situation. Lastly, 
it is highly probable that this visible lymphangiectasia 



136 



PHLKOMASIA DOLENS WJTH LYMPHATIC VAHIX. 



was not tte result of any special inflammation or obstrnc- 
tion to the course oi the lymph in theso parts, but that 
the obatruction was general in the limb ami produced 
visible lymphangiectaais where the skin, aa aforesaid, was 
weakened by skin cracks. Had there been skin cracks 
elsewhere in the limbs, we should have expected lymphan- 
giectasia in tho same places. Probably the whole lym- 
phatics of the limbs were distended, but became visibly 
varicose at the affected parts, because there imperfectly 
supported. 

The temperature variations during her stay in hospital 
were very slight, between 99° and lOO'S", only on three 
evenings rising above 101°, and only once among these 
as high as 101'8°. There was a rise generally of only 
about "5 during the first five days of the phlegmasia of 
the right leg. For ten days before she left the house the 
temperature was normal. 

Similar transformations of akin cracks, or the simulta- 
neous occurrence of skin cracking and lymphatic disten- 
sion, are often observed iu the skin of the abdomen of 
pregnant women and elsewhere ; and I have often pointed 
them out to pupils. These varying conditions of skin- 
cracks have given rise to the chief differences that are 
so striking in the descriptions by different authors of 
abdominal skin-cracks in pregnancy. 

Although, as already said, I do not enter on the general 
subject, but merely make commenta on an individual case, 
I cannot avoid referring to the most valuable paper of 
Dr. Busey, published in the fourth volume of tho ' Tran- 
sactions of the American Gynecological Society,' entitled 
" A Contribution to the Pathology of the Cicatrices of 
Pregnancy," the last and best work having reference to 
my subject. 

S, H — , fflt. 42, admitted into Martha Ward, November 
17th, 1880, Has been twice married, first twenty-six 
years ago, and again nineteen years ago. Catamonia 
began at eleven years, and have been regular till about a 
year ago. Had one child twenty-five yewva ago. 



PHLEGMASIA DOLENS WITH LYMPHATIC VARIS. 



137 



About once a year, for the last seven years, she has had 
a flooding. Four years ago it was so severe that she 
was admitted into Soho Square Hospital. She says that 
these floodings were not oonnocfed with miscarriage, and 
that there was no fetid discharge at these times. 

Her present illness began with a severe flooding ten 
weeks ago. It lasted, with intermissions, for a fortnight 
and made her weak and bloodless. Eighteen days before 
admission she began to suffer pain in the left leg, espe- 
cially along the inner side of the thigh in the course of 
the internal eaphena vein. Four days after the pain 
began the calf of the leg swelled rapidly, and this state 
extended downwards and upwards to involve the whole 
limb. The swelling gradually increased for about ten 
days and then began more slowly to diminish. 

At present she is thin, aniamic, and her face has an 
expression of anxiety and of suffering. Her tongue is 
clean. Bowels regular. Appetite small. Micturition 
easy, urine natural. Pulse feeble, regular, 121. Heart 
sounds normal. Reap. 30. Temp. Oft". Lungs healthy. 
Examination of hypogastrium discovers nothing abnormal. 
Inguinal glands somewhat enlarged and tender, and 
similar swelling and tenderness in the region of the 
saphenous opening. The left limb is swollen from hip to 
foot, the leg more so than the thigh. The whole lirab is 
tender. The thigh does not pit on pressure, while the 
leg and foot do so. On the outer side of the upper part 
of the left thigh, over a space as big as the hand, are 
numerous pearly projecting lines, which feel distended and 
have the characters of lymphatics. On pricking two of 
the largest, slightly viscid lymph comes outj it is a 
clear fluid, and under the microscope showg numerous 
corpuscles like those of lymph. 

On the opposite or right thigh, and nearly in the same 
situation as is occupied by the lymphatic patch on the 
loft, is a patch having some resemblance to it, but it is 
evidently caused by mere fkin-cracks. They are elongated, 
spindle-shaped, blnif'li spaces, closely resembling the akin 



]:3S 



PHLEGMASIA DOLENS WITH LYMPHATIC VAEIX. 



cracks on the patient's abdomen. They are felt to be 
easily depressed or to be really depressions between beams 
of uninjured akin. They have a dead aspect, not a pearly 
luetre. They are straight and ribbon-like, whereas the 
lymphatics o£ the left patch are fretted, continuous, 
auatomosing, and at parts somewhat moniliform in out- 
line. 

Examination per vaginatii discovers an advanced con- 
dition of malignant disease of the cervix uteri, it being an 
irregular semi globose mass, fixed, not hard, having 
nodosities, not in the mesial line, but as if pressed towards 
the left thyroid foramen ; it bleeds a little when 
touched. The discharge is very slight. 

It was ordered to administer food liberally and to keep 
the leg in hot flannel fomentation, 

November 23rd. — Leg diminishing in size, and paiuful 
only when handled. Four inches above the knee it 
measured on the I7th ISJ inches in girth, while the right 
was 12J; now it is only 13^ inches. On the 17th the 
calf measured 164, while the left was 10| ; now it is only 
13J. 

25th. — At the upper margin of the area of lymphatic 
dilatation two vessels give the examining finger the 
feeling of being plugged by clot;- nearly half an inch long. 
These thrombosed portions are just above the pricks made 
to lot off the lymph. 

27th. — Leg still less in size, and presents little or no 
tenderness. General condition greatly improved. Pulse 
112, temp. 100'4°. Lymphatic distension has disap- 
peared. 

December 4th. — Slight attack of phlegmasia dolens in 
the right leg, which is swollen and tender, and pits on 
pressure. Now the patch on the right thigh closely 
resembles the lymphatic patch on the left, only the 
vessels are not so large and distended. The skin-cracks 
are now with difficulty made out. Pulse 90, temp. 100". 

10th. — The swelling of the right leg has gone, leaving 
only puffiness of the ankle. Pulse 90, temp. 98-6°. 



PHLEGMASIA D0LEN8 WITH LYMPHATIC VARIS. 139 

January 4th. — The swelling of the legs has disappoBred. 
She feels well, and walks about, but is losing flesh. The 
patches on the thighg are nearly alike; both have more 
the appearance of lymphatic patches than of patches of 
ekin-cracks. In both, and especially ne-ar the margins of 
the areas, skin-cracks are now to be found distinctly when 
looked for, and mort? easily in the right than in the left 
thigh. 

7th. — Dismissed. 



Dr. Platfjub said that he had himself no doubt of tlie 
accuracy of the theory of phlegmasia dolens adyerted to by 
I>r. Dunoan, viz. that, in addition to the thrombosis of the 
venous trunks of the aitected limb, there was also some affec- 
tion of the lymphatics, and this was his view of the disease be 
bad himself adopt-ed in his work on ' Midwifery.' There were 
many clinical facts which proved to demonstration that throm- 
bosis of the venous trunks was not of itself sufficient to account 
for the phenomena of the disease, although from ita fadhty of 
detection it had naturally enough received much attention. 
Amongst these might be mentioned, by way of illustration, the 
well-known thrombosis of the veins of the lower extremities 
occurring in gouty subjects, in connection with which nothing like 
phlegmasia dolens was observed. What I>r. Duncan's cases did 
seem to him chiefly to prove was the probably intimate relation 
between a certain amount of septic absorption and phlegmasia. 
The occurrence of more or leaa septictemia before puerperal 
phlegmasia had frequently been point«d out, and he bad no 
doubt himself of their intimate relation. It was curious that true 
phlegmasia was far from uncommon in connection with malignant 
disease of the uterus ; this existed in both of Dr. Duncan's cases, 
and it can be readily understood how septic absorption might 
frequently occur in a disease attended by much destruction of 
tissue, and characterised by abundant fetid discharge. Dr. 
Duncan stated his behef that lymphatic irritation or obstruction, 
or whatever the condition of the lymphatics might be, bad 
more to do with the production of phlegmasia than venous 
thrombosis. It did not seem to him (Dr. Playfair) that there 
was any sufBcient ground for such an assumption. Certainly, 
iu these cases there was marked evidence of great lymphatic 
romplieation in the form of lymphangiectasis, but he had never 
seen anything analogous to this in puerperal cases, and probably 
it resulted from the peculiarly acrid and irritating character ot 
the discharges in cancerous dieease. On the contrary, there was 
a certain class of chnical facts, which he bad formerly alluded 



140 



PHLG0UA8IA DOLSNS 1 



I LVUPHATIC VAEIX. 



to in writing on this subject, which ehowed that in niB.iiy cases 
of phieg^masia the atartiag-point was venous thromboaia. Such 
were cases io which there was marked evidence of centraJ venous 
thrombosis, in the pulmonary artery, for example, which preceded 
for a considerable time the a,ppearance of phlegmaHia in the 
limbs. There could be no doubt that, under such circumatanceB, 
the central and peripheral thrombi were produced by similar 
causes, and were the main factors in the disea,ae. He was, at 
the present time, seeing daily a lady whoae caae formed an 
admirable example of this clmical fact. She ha,d had a very 
• difficult labour, followed by a shaq) attack of aeptiraemia, 
Towards the end of this she showed symptoms of pulmonary 
obstruction, dyspnoea, palpitation, and the like, and along with this 
a loud systolic pulmonary murmur was developed, the inference 
being that a thrombus had formed in the pulmonary artery. 
Some ten days or more after this, and when the cardiac 
symptoms had much abated, she developed a large phl^masia 
in the left lower extremity. Did not this sequence of events 
clearly show that she had first septicDsmia, then central 
thrombosis, and lastly peripheral thrombosis ? A case like this 
certainly gave no support to the theory that the main agent in 
the production of the disease was lymphatic obstruction. 

Dr. Graxlt Hewitt agreed with the Proaident in his estimate 
of the importance of the late Dr. Tilbury Fox's paper on 
phlegmaaia dolens. There aeemed to be little doubt that in 
typical cases of this disease both lymphatics and veins were 
aifected. He believed that the lymphatic coagulation and 
obstruction resembled that of the veins. It was known that 
as regards the venous obstruction it originated — probably 
always — in coagulation in the uterine sinuses extending into 
the iliac trunk; it was reasonable to infer that the lymphatic 
vessels might become similarly affected, and that the mechaniam 
of the lymphatic obstruction resembledthatobseiwed in the veins. 
The conjunction of the two obBtructious constituted phlegmasia 
dolena. 

The President would not attempt to estimate precisely the 
comparative extent of influence in phlegmasia dolena of venous 
and of lymphatic obstruction. He would only say that while 
sometimes venous obstruction was certainly absent, we could not, 
in the present state of our knowledge, say the same of lymphatic 
obstruction. In advanced pregnancy, without active disease, 
venous obatmction was often proved by venosity, and by varicose 
veins of the lower limbs. Such evidence of ot«truction did not 
reach higher than the brim of the pelvis. On the other hand, 
lymphatic cedema and varis were common in the lower limbs, 
and also in the lower part of the anterior wall of the abdomen, 
especially in multiporce, and above the brim of the pelvis. 



A CASE OF EXTRA-UTERINE, ASSOCIATED 
WITH INTRA-UTERINE, FCETATION, IN WHICH 
ABDOMINAL SECTION WAS PERFORMED. 

By Alpeed L. Galabin, M.D., F.R.C.P. 

On the evening o£ June ISthj 1880, 1 received an urgent 
message from Mr. Thomas Duke, of Rugby, asking me to 
come down to see a patient who was in imminent danger 
from ruptnre of an ovarian cyst, associated with pregnancy, 
and to be prepared to perform ovariotomy at once. I was 
unable to reach Rugby until the afternoon of the 19th, and 
I then obtained the following history from Mr. Duke, to 
whose minute and accurate observation of the case 
throughout I am greatly indebted. 

Martha E — , eet. 36, was married for the first time in 
the spring of 1878. In the summer of that year she had 
an abortion. On April 2lBt, 1879, she was delivered by 
forceps of a fine male child. There was a slight rupture 
of the perineum, but she made a good recovery. She 
engaged Mr. Dnke to attend her in her second confine- 
ment, which she expected in September, 1880. In April 
aha came to him, complaining of a pain in the right side, 
which she attributed to a fall over a chair. On Juno 3rd 
he was sent for, and found her in bed complaining of 
great pain and teuderness on the right side. Ou ei^ami- 
□atiou, the abdomen was found much distended. The 
^^ distension was caused by two tumours, one of which occu- 

^^ pied the pubic, left inguinal, and iliac regions ; while the 

^B other, quite distinct, occupied the right iliac, moat of the 

^H umbilical and epigastric regions, and pushed up the liver, 
^^1 so that the tumour caused the ribs of the right side to be 
^^M distinctly elevated. It caused an obvious prominence on 
^B the nghl side, and pasiied backward towards the spine. 
^H There was a distinct sulcuB between the two swellings, 

^^k broad enough to pass a finger between them, and the oat- 



142 



SZTRA-UTBBINB COlirLICATED WITH 



lines of tbe two were distinctly felt. Fluctuation was felt 
in both, Fcetal movements, the fcetal Leart sounds, and 
the uterine souffle were distinctly to be discerned in the 
laft tumour, which was evidently the pregnant uterus. 
In the right tumour fluctuation only could be detected. 
She said that she felt the movements of a child, but in the 
left-hand swelling only. A diagnosis was made of ovarian 
tumour complicating pregnancy, and two other medical 
men who saw the patient agreed in this diagnosis. 

She was ordered to remain in bed and keep quite quiet. 
On the 10th, however, she was so far better that she 
walked to Mr. Duke's house, still complaining of pain ou 
the right aide of the abdomen. A few days later pain 
again increased, and sickness began, with increased tender- 
ness. On the night of the IGth she complained suddenly 
of great pain and faintness, and sent for Mr. Duke. When 
ho reached the house he found her in great pain — moaning 
and tossing about, cold, and with a quick pulse. The 
outline of the right tumour had disappeared, and fluctua- 
tion was now to be felt ail over the abdomen, with increased 
swelling. She continued thus, in great pain and growing ■ 
weaker, until, on the morning of the 18th, Mr. Duke sent 
for me, considering that an exploratory operation would 
probably give the only chance of saving her. 

When I examined the patient on the following day, 
the pregnant uterus, displaced towards the left side, and 
corresponding in size to between the sixth and seventh 
month of pregnancy, was readily to be made out, and the 
fcetal heart sounds were readily audible over it. The 
abdomen was greatly distended, and over its right side 
und upper portion there was general fluctuation. On deep 
pressure to the right side of the fundus uteri some more 
solid mass could be detected, and, on vaginal examination, 
what appeared to be tbe same mass could just be reached 
behind and to the right side of the cervix. There were 
geneml signs of peritonitis, pain and tenderness of the 
ubdomeu, and small, rapid pulse. The pulse-rate was 140, 
temperature about 100". Nothing whatever could be 





d of tfe ■■IJi Ml -4a» ph 



^L bee 

^H cav 



■nfaee<< Ae rigte ^rrr»-1 Bgimnil, and 
-Ann «a« no obrktmly deUobei 
itiwilmwiit maat bkTo oocDired to 
tlw Wjiiiui iLiftft. nie sbmII intesdiMs ehoired 
endeooeof mij- perifamitis, ind won so grMtly distondikl 
tfaat nraeh difficolty was eaperienoed in keeping theuk 
witlmi the abdomen dnring the operaUou. The ptn-ito- 
Deam w«a sponged out, the pUoenu being left atoMc 
"nie funis was fixed in the wonnd with a glaM draiiin^vt 
tabe, which entered the gptn-ral peritouoal cavity, i Thi* 
membraiies tore so readily that it would not hnvp lii>iiii 
possible to stitch them to the edgef> of the wimiiil m\ m tt> 
shut off the general peritoneal cavity, had nioli a i"our«« 
been thought desirable. Moreover, tlio blood wItliiU Imd 
been efFnsed wau found altiiost untinOy t>i Mik imrittxii'itl 
cavity, the liquor nnrnii which reuaiuod witlilii llid iiivtii- 



144 



BXTEi-CTERIHE OOMPtlCATBD WITS 



branea being almost free from blood. Tlie operation had 
been performed under carbolic aprayj and the wonnd was 
dressed with carbolic gauze, a cup-shaped sponge wrong 
out of carbolic solution being placed over the end of the 
drainage tube. 

The child, a female, was dead, but not decomposed. It 
measured 14^ inches in length, but weighed only IJ pounds, 
.X)n the evening after the operation the patient waa 
very faint; temp, 99"8°, pulse 144. The dressings were 
moistened with some sanguineous fluid, which escaped 
through the drainage tube. 

On the morning of the Slat there waa still some 
escape of sanguineous fluid, but only in alight amount. 
The patient was very sick. Temp. 99'3°, pnlse 148. 
Evening : temp. 99'7°, pulse 144, She seemed much 
stronger, and sickness had ceased. Wound dressed anti- 
septically. 

On the 22nd, at 5 a.m., Mr. Duke was sent for, and 
found hep in labour, the paius having come on about 
2 a.m. After giving a subcutaneous injection of ergotine 
he ruptured the membranes and brought away the fcetua, 
which presented by the breecb. The placenta followed 
immediately. There was hardly any hajmorrhage from 
the vagina, but a great deal through the drainage tube, 
and the patient was very faint after delivery. The child, 
a male, showed no sign of life, but was not decomposed. 
Length 1(34 inches, weight 2^ pounds. Later in the 
morning, at 10.45, she was still very faint, but could keep 
down beef tea, milk, and brandy. There was still some 
hEemorrbage through the drainage tube, but in diminished 
quantity. Temp. 98"7°, pnlse 142. In the evening she 
seemed wonderfully strong and free from sickness. 
Temp. 99'4°, pulse 13(3. Wound dressed antiaeptically. 

On the morning of the 23rd temperature had become 
normal, 'J8'4°, pulse 136. There waa no sickness nor 
pain, and she still seemed wonderfully well, and had had 
a good night. Hemorrhage through the tube, however, 
atill went on during the day and following night. In the 



rNTHA-UTBRimi PCETATION : ABDOUINAL EEOTION. 



145 



evening she bad become very feeble ; temp. 99°, pulse 
146, and she died at 5 a.m. on the 24tli. On the evening 
of the 23rd the wound had been dressed antiseptically, 
and the glass tube replaced by a large india-rubber 
drainage tube. The discharge through the tube appeared 
to consist of pure blood, and was throughout quite free 
from smell. No autopsy was allowed, but it was noticed 
that the abdomen was ooneiderably distended after 
death. 

The hemorrhage, which appeared to be the cause of 
death, was probably due to the shrinking of the uterus in 
the expulsion of the fcctus, and consequent further 
detachment of the extra-uterine placenta from its posterior 
wall. It would seem that the patient might have been 
saved if this had not occurred. 

I think that one or two points in reference to the opera- 
tion of abdominal section for extra-uterine fcetation are 
suggested by the present case. First, that if the fcebus be 
enclosed only in thin membranes, and not in any firm 
adventitious sac, it would be aseless to attempt to stitch 
the membranes to the external wound, shutting off the 
peritoneal cavity, and to drain the cavity of the membranes 
only. Supposing the placenta to become disintegrated, 
the products of the disintegration would probably reach 
the general peritoneal cavity, as the effused blood had in 
this instance, rather than get into the amnial cavity by 
breaking through the amnion. It may be a question 
whether, if the funis were cut short and the wound com- 
pletely closed, supposing the antiseptic method to be 
perfectly carried ont, the plaoenta might not remain 

I quiescent without decomposing^ as it does in those cases 
in which both fcctus and placenta are retained for years 
within the abdomen. 
Secondly, it would seem that in this case hasmorrhage 
from the site of detached placenta was still going on up 
to, probably, seven days after the death of the extra- 
nterino foetus. Hemorrhage bas also been the cause of 
death in other cases of abdominal section tor extra-uterine 
VOL. XIlll. 10 



146 



IZTBA-irrBBIHS COKFLIOATSD WITH 



foetation, aB in that recorded by Dr. Gervis, even when 
the placenba has beeo left alone as far as possible. I 
think it may be inferred that if htemorrhage is going on 
at the time of operation, and its site can be detected) or if 
it is caused by nnavoidable partial separation of the 
placenta in carrying out the operation, it may bo desirable 
to apply some styptic, as sobsulphate or perchloride of 
iron, to the bleeding site. The persistence of hiemorrhage 
in this instance would hardly be enconraging for the plan 
of separating the rest of the placenta, even if part had 
been spontaneously or accidentally detached, in the hope 
that heemorrhage wonld afterwards cease. 

It will be noted that in the present instance there was 
no history of previous difficulty of conception or a pre- 
ceding period of sterility of some years, as there often is 
in cases of extra-uterine pregnancy. On the contrary, 
including the extra-uterine fcetus, the patient had con- 
ceived four times within two years. This circumstance 
may perhaps be connected with the ectopic foetation 
occurring in a case of twins, and it is remarkable that the 
only two similar cases in which I have been able to find 
an esact record of previous prognauciea corresponded with 
mine in this particular. In one of these delivery at full 
term had occurred six months before the twin conception, 
of which one ovum was extra-nterine ; in the second a 
miscarriage had happened only two months before. 
According to Dr. Parry's statistics, out of 500 oases o£ 
extra-nterine fcetation there were twenty-two cases of 
combined extra-uterine and intra-uterino pregnancy, and 
probably two other caseg in which two fecundated ova 
both remained outside the uterus. From these data it 
would foUow that twin conceptions are at least four times 
as frequent in extra-uterine as they are in normal fceta- 
tion, the general average of twin pregnancies being about 
one in ninety. This is evidence in favour of the view 
that one ovum may impede another in entering or passing 
along the Fallopian tube ; and in the present case the 
extr&>uterine fcetation may have been due to this causa 



I 



INTEA-UTBIirNE fISTi 



ABDOMINAL SKCTION. 



147 



t 



rather than to the effect of Boy adhesion or to organic 
impediment to the patency of the Fallopian tube. 

Tbo lengths and weights of the two fcetnses appear to 
correspond with the view that both were conceived at the 
same time, and that the time correaponded with tho 
supposed duration of pregnancy, namely, about six and a 
half mouths. The slight inferiority iu length (14^ com- 
pared with IGi inches) and considerable inferiority in 
weight {IJ compared with 2^ lbs.) of the extra-uterine 
foetus may bo accounted for by the greater difficulty of its 
nutrition, owing to its abnormal position. This would 
probably have more influence when another fcetus existed 
in the uterus than in cases where an extra-uterine foetus 
is alone present. The comparatively small bulk of the 
extra-uterine foetns may to some extent account for the 
fojtal heart not having been detected over the extra- 
uterine sac, while it was easily heard over the uterus. 

Among similar cases recorded, I have not been able to 
find one in which a complete diagnosis was made while 
both extra-uterine and intra-uterine foetus were within the 
abdomeu, and the reports of several of them show that tlje 
complication has been found perplexing. 

In the fiffh volume of our ' Transactions ' Mr. L. B. 
Cooke records a case of a woman 39 years old, in which, 
at the onset of labour, the pelvis was found occupied by 
a tumour. Suspecting extra-oterine fcetation, he sent for 
Dr. Greenhalgh, who thought that the case was probably 
one of ovarian tumour complicating pregnancy. He sent 
also for Mr, Spencer Wells, who detected a double ftntai 
heart, and thought that there was twin uterine pregnancy. 
The double foetal heart had pnt him off the scent, since it 
did not occur to any one that one fcetus might be inside 
the uterus and the other out. Eventaally delivery was 
accomplished by Dr. Greenhalgh by pushing up the tumour 
and extracting by version. The patient died in forty-eight 
hours, and an extra-uterine fcstns was foand at the autopsy. 

In the 'Lancet ' of Jnno 20th, 1863, Mr. J. Pennefather 
records the case of a lady aged thirty-eight, who became 



148 



BlTEA-Di'ESrNT! COMPLICATED WITfi 



pregnant in October, 1861, after a miscarriage in August. 
On April 3rd she was attacked by violent pain, followed 
by enormoua distension. She waa, however, delivered 
normally of a fnll-grown female child on September 4th. 
A swelling was still felt in the abdomen, and Mr. Penne- 
father heard the fcetal heart, and diagnosed the extra- 
nterine fcetation. Dr. Oldham afterwards saw the patient, 
and thought it a case of ovarian tumour. Dr. Ramsbotham 
also saw her subsequently, and agreed with Mr. Penne- 
father. The patient suffered from hectic up to February, 
1863, when a puncture was made by trocar, but only faeces 
passed through it. Subsequently foDtal bones escaped 
through the vagina, and faeces for some time passed the 
same way, bnt on May 14th, the date of the report, the 
patient was doing well. 

Dr. Sale records the case of an unmarried Negress, in 
whom extra-uterine fcetation was diagnosed. Abdominal 
section was performed, and a living extra-uterine fcetus, 
with the placenta, was extracted. The uterus waa then 
found to contain another child, whose existence bad not 
previously been suspected. This was removed by hystero- 
tomy, and the patient died on the fourth day from 
eepticEemia ('New Orleans Medical Journal,' October, 
1860, and ' Brit. & For. Med.-Chir. Eev., January, 1872). 

In a case recorded by Deocene, according to Parry's 
report, the history waa similar, but I have not been able 
to refer to the original account of this. Dr. Parry's refer- 
ence being incorrect. 

It is to be observed that in most of the cases the extra- 
nterine pregnancy seems to have been of the abdominal 
variety, and to have gone on up to the time of labour 
without causing any very dangerous symptoms, if not 
interfered with. 

Thus, in a case recorded by Dr. Satterthwait, that of a 
woman aged thirty-fivo, nothing was discovered during the 
pregnancy, but a severe instrumental delivery, occupying 
from eight to ten hours, was required. This was followed 
by a dangerous illaess of five or six weeks, and an enlarge- 




IKTBi-UTEBINE FETATION : ABDOMINAL SECTION. 



UO 



ment in the abdomen was Jiscoyered. EveDtually the 
fcBtal bones were passed or extracted by the vagina and 
rectum, aud the patient recovered (' New York Medical 
Journal/ 1872, vol. xvi). Dr. Starley reports a case in 
which the tumour was only noticed after the delivery o£ a 
living child. Movements of the extra-uterine fcetus were 
felt up to within a few days of the time when he saw the 
patient, which was seven weeks after delivery. She was 
thought to be too exhausted to survive surgical inter- 
ference, and died two days later ('New York Medical 
Journal, March, 1 873) . In a case recorded by Dr. 
London, and reported by Dr. Campbell, in his ' Memoir 
on Eitra-Uterine Gestation,' p. 65, and in one recorded 
by Dr. Pollak ('St. Loaia Medical and Surgical Journal,' 
May 10th, 1871), the extra-uterine tumours were also not 
discovered until after the laboor, and this was eo also in 
a case recorded by Mr. J. Clarke ('Medical Times and 
Gazette,' December l:ith, 1856). 

In a recent case, recorded by Dr. Wilson (' American 
Journal of Obstetrics,' October, 3880) the patient was 
delivered of her fourth child one month before full term. 
A tumour distinct from the uterus was detected for the 
first time in the abdomen after delivery, and was found to 
contain a still living child. Abdominal section was 
performed twenty-six days after delivery and a living 
child extracted. The cyst was considerably adherent, and 
was stitched to the abdominal wall. An inch of the 
wound was left open, with the funis passing through it. 
The discharge became offensive, and febrile symptoms 
arose. Three days after the operation on attempt was 
made to remove the placenta after opening up the wound, 
but hfemorrhage compelled its abandonment. The patient 
died ninety hours after the operation. The placenta was 
found in three parts, attached to the left side of the 
uterus, the lefb Fallopian tube, and left iliac fossa. 

In the present case the occurrence of hiemorrhagc was 
probably due to the oxtro-utorine placenta having been 
attached in part tq the external surface of the uterus. 



150 



ABDOHtHAL SECTION IN nTERlNE I 



The intermittent contraotioiiB of the uterus during preg- 
nancy would he not unlikely to cause Bome detachment or 

rupture of veBsels. 

In most, if not all, of these cases the extra-nterine and 
intra-uterine ftetua would seem to have been twins, and 
this would agree with the view of possible causation by 
the interference of one ovum with the other. The follow- 
ing case, however, appears to prove that ovulation may 
sometimes occur during the development of an extra- 
uterine fcetua. It is related by Dr. Frank Argles in the 
'Lanoet' for September 16th, 1871. The patient was 
believed to be pregnant, and the movementa of the child 
ceased on April 10th, Three days later an ovum of two 
months' development was expelled fi-om the uteme. 
Death took place on July 9th, and at the autopsy an 
extra-uterine foetus of about seven months' development 
was discovered. 



Dr. RonrH thought it would be a pity, if ao auperior a paper 
aa Dr. Gtalabin'a should pass without dlscusBion. He could not 
but congratulate Dr. Galabin on his skill and powers of diagnosis, 
as he was the only oue who bad diagnosed the extra-uterine 
pregnancy. He would, however, venture to make one sug. 
gestiou, and that was as to the htemorrhage. This, which 
occurred at first before the labour of the second child, would 
not possibly have proved fatal, but it was no doubt materially 
increased by the contraction of the uterus after the labour (if he 
understood Dr. Oatabin right). The ploceute of the extra-uterine 
child was attached both to the abdominal parietes and the 
uterus itself ; therefore, as the uterus contracted, the placenta 
must in part have been more separated, hence the cause of 
increased hEemorrhage. Now, he thought if the abdomen had 
been then reopened, and the hEemorrhage found out, it might have 
been arrested by the actual cautery. To re-open the abdomen 
after ovariotomy was sometimes advantageous, even in cases 
of peritonitis — aa had been proved by foreign operators, and 
here Dr. Prothero Smith had done so suecessfutij in another 
case of ovariotomy and reopened the abdomen and saved life. 
So much being admitted, could not the actual cautery have been 
used here also to arrest the htemorrha^ P He remembered a 
case of ovariotomy by Mr. Baker Brown, in which he (Dr. 
Kouth) had assisted him, aud where the adhesions to intestines, 
parietes, and even liver were uumerons (eight or ten), in w'nich 



STATISTICS or WIDWIFEEY IN PKIVATB PRACTICE. 



151 



I 



heemorrhage occurred, and where all was arrested readily by t.he 
actual cautery, and the patient made a perfect recovery. PortioDs 
of uterus he had also seen cut away io orarian or fibroid opera tion§, 
and the bleeding in lite manner arrested by the actual cautery. 
Perhaps if this could have been done here, the patient, who 
evidently died from the bleeding, might have been saved. 

The Pkesidknt regarded uncontrollable hiemorrb^e as the 
great difficulty in surgical interference with extra -uterine 
pregnancy, and this even many months after death of the fcBtus. 
He did not look with much hope on the actual cautery as a 
means of arresting this or any kind of heemorrhage. In his 
wards ho had lately seen it used in vain by Mr. T. Smith in an 
oozing from the liver in ovariotomy ; and he had, the previous 
day, found it inefficient in controlling the htemorrhage from a 
vessel injured in removing a small piece of lupus of the vulva. 

Dr. Q-ALABiN said that, on account of the distance of the 
patient, be had not bad the opportunity of deciding on the 
exiwdiency of reopening the abdomen. He thought that a 
styptic, such as perchloride of iron, would be more effectual than 
the actual cautery in arresting hemorrhage in such a case. 



STATISTICS OF MIDWIFERY IN PRIVATE 
PRACTICE. 



By GEODflE RlQDEN, 



I 



Bklirvino that the following record of midwifery oaaes 
that have been under my immediate care during the last 
forty-three years, viz. from 18S8 to 1880 incluaive, might 
be of some value to the Society, I have made a rongh 
analysis of them, and regret that more minute records 
were not always made at the time of their occurrence, so 
ns to make the report a more vuluable addition to the 
records previously prepared by Drs. Rose, Godson, and 
others, which have already bevu published in the aDunal 
volume uf 'TrausactioDB.' 

Thia midwifery practice has h«ea among nil cla.s.sei» of 



152 



STATISTIOB OP JCIDWIPKET IK PBIVATi PRACTICE. 



the community residing in this city and immediate 

neighbourhood J with the exception of the absolute paupers. 
And, as there is no lying-in institution in this neighbour- 
hood, they have all been attended at their own homes. 

Daring this period I have personally attended S682 
women who have been delivered of -5751 children, viz. 
2947 males and 2804 females — 65 of these were twin cases, 
one mother giving birth to twins four times, viz. at her 
second, third, fourth, and fifth confinements, and never 
after becoming pregnant, and there were two cases of 
triplets, the six children being born alive. 

5422 children presented with some part of the head, 
including the face. 
156 were cases of breech presentation, including the 
hips and loins, 
89 were presentations of the inferior extremities, 

including the knees and feet. 
84 were presentations of the superior extremities, 
including the shoulder, elbow, and hands. 

Some of these cases were complications of two or more 
of these divisions. 

There were 45 oases of placental presentation, either 
entire or in its greater part, and these cases are included 
in the above division. 

255 of the children were stillborn, 165 being premature, 
at periods of pregnancy of six and a half to eight months, 
many of which were probably expelled in consequence o£ 
their death, and 90 others were stillborn, but for which 
no cause is assigned in the record, 105 of the children 
had been dead a considerable time previous to their expul- 
sion, as is evidenced by its being recorded that the cuticle 
was separating. 

The stillbirths were consequently in the proportion of 
one in twenty-two, or about 4'4.per cent. 

56 of the stillborn children were delivered by version; 
19 wore presentations under the first division, viz. the 
head, forehead, or face; 26 were under the fourth division, 
viz. shoulder, elbow, or hand ; 4 were presentations of 



STATISTICS OP MIDWIFERY IN PRIVATE PBACTICK. 153 

both arms and face; and 7 were casee of placental 

presentation. 

259 of the children were delivered with the forceps, and 
in 2 cases the head bad to ba perforated previously to 
delivery. In no case has promature labour been inten- 
tionally brought on by manual, instrumental, or other 
means. 

In the first 2000 cases, or those previous to the year 
1860, the forceps were used bnt nine times, or about once 
in 222 cases, while daring the last twenty years this instru- 
ment has been had recourse to 250 times, or about once in 
fifteen labonrs. The proportion of stillborn children was 
but very slightly in excess during the former period in com- 
parison with the latter, bnt I do not attribute this slight 
advantage to the more frequent use of the forceps, as 
something may be due to more mature experience in the 
management of these cases. The mothers have, however, 
derived considerable advantage by having their sufferings 
and anxiety relieved much more quickly, with less labour 
to themselves, and consequently their convalescence haa 
been less protracted. 

In the early part of my practice ergot was very fre- 
quently, and the tractor occasionally, though but rarely, 
used, but I could never obtain the certain advantages 
from either that I expected and wished for, so that for 
the last twenty years I have entirely abandoned the use of 
the latter, and have only occasionally administered tho 
ergot, placing my entire confidence in the forceps as the 
most efilcienl expedient for accelerating the labour when 



K fine 



The proportion of stillborn children appears to be large 
as compared with some statistics previously published, but 
it must bo borne in mind, not only that a very large pro- 
portion of these were prcmatore, bnt that they were all 
attended at their own homes, many of which with very 
ipetent nurses, so that it baa not been nncommon to 
find a child expelled with the cord tight round its neck 
prerions to my arrival, or to find the child smothered it\ 



154 BTATISTICa OP HIUrnrKBT IN PBITATS PKACTICE. 

the bed-clotbes. It is quite evident that the forceps 
cannot have increased the infant mortality, but more 
probably hae reduced it, inasmuch as the in^nt 
mortality in the forceps cases, which would certainly 
include those the most difficalt, was but in the proportion 
of one in seventeen. 

Of the craniotomy cases, the first occurred many 
years since in the person of ' a primipara aged abont 
twenty-five. She had been in labour many hours, and 
although I was assisted by two experienced practi- 
tioners we were unable to place the forceps firmly over 
the head, which, apparently from its extreme size, would 
not enter the pelvis. This person made a good recovery, 
and has since given birth to several living children withoot 
much difficulty. The second case occurred but a few 
years since in the person of a woman, aged about twenty, 
who had previously given birth to a living child at 
full term. This was a breech presentation, and the body 
of the child being already bom, it was fonnd impossible 
to make the head enter the pelvis. There could be no 
doubt of the child being already dead, therefore the head 
was perforated, and an enormous quantity of serous fluid 
escaped, showing that the difficulty was occasioned by the 
child being hydrocephalic. This woman has since given 
birth to a living child at full term without much difficulty. 

The placental presentations may be divided into two 
divisions, viz. first, where the placenta was only in part 
over the oa uteri, and the hand could be insinuated between 
it and the uterus, the child was delivered as early as possible 
by version, and the placenta afterwards removed, and with 
but very few exceptions these children were born alive ; 
and secondly, where the placenta was entirely over the os 
uteri and actually bulging into the vagina, of which there 
are seven cases recorded, the placenta has been removed 
previously to the removal of the child, and in all these 
cases the child was stillborn. The danger from this 
complication is entirely due to heomorrhage, but there have 
certainly been no maternal deaths from this cause, nor have 



STATISTICS OF MIDWIFERY IN PRIVATE PRACTICE. 155 

there been any cases of eafficient danger to be noted in the 
record. My practice has invariably been — if the os uteri 
is sufficiently dilated, or if not, to dilate it either by plugging 
or by the fingers — to empty the utems by turning as early 
as possible, and on no account to leave the patient until 
the uterus has firmly contracted. There is no doubt but 
that this practice, although possibly attended with some 
disadvantage to the child, has materially contributed to 
the safety of the mother. Exceptions to this treatment 
have only occurred where the htemorrhage baa been very 
slight, and these cases may often best bo treated by entire 
rest in the recumbent position which will generally enable 
the mother to go to her natural term in safety both to 
herself and her infant. 

There have been IS maternal deaths from various causes, 
viz. 2 from puerperal convulsions and coma, 5 from puer- 
peral peritonitis and fever, 2 from heart disease and dropsy, 
1 apparently from fright, 1 from cancer of the tongue, 
1 from bronchitis, which bad exhausted the woman 
previous to the commencement of labour, and 1 from 
scarlatina. 

Of the cases of convulsions, &c., the first was an im- 
becile unmarried female, aged about nineteen years, in 
labour with her first child. She had been subject to 
epileptic fits for several years. She continued to have 
convulsions every few minutes during her labour, but was 
delivered by the natural efforts in one of them. She 
became, however, comatose, and died about six hours after 
the termination of her labour. She was bled, ice applied 
to her head, and a large dose of calomel administered, but 
without any beneficial effect. The second case was in 
the person of a mother, aged about twenty-three, who 
had previously, with the aid of the forceps, given birth 
to a living child. Her labour on this occasion was 
natural in all respects and terminated by the natural 
efforts. The convulsions did not commence until twenty- 
four hours after the termination of the labour, but continued 
with slight intermissions for twelve bours, when she died 



156 STATISTICS OF HIDWIFERT IN PRIVATE PKACTICE. 

iu a state of coma. Slie waa treated with bleeding from 
the arm, cold application to the head, and calomel 
administered. Five other cases of convulsions during 
labour are recorded, which were treated in the same 
manner and recovered. 

The first case of peritonitis occurred in excessively hot 
weather in a badly ventilated apartment — a primipara, 
aged about thirty, delivered, after a very protracted 
labour, with the forceps of a living child. On the third 
day after her confinement rigors appeared, followed by 
peritonitis and fever, which terminated fatally on the 
seventh day after labour. 

The second case of peritonitis was iu the person of a 
primipara, aged about tweuty-five, delivered by the natural 
efforts and without difficulty of a living child. It appeared 
that her attendants were not sufGciently careful abont the 
proper airing of her clothing, and that a chill was 
produced on the second day, which quickly terminated in 
peritonitis and fever, and proved fatal on the sixth day after 
delivery, 

The third case of peritonitis was in the mother of 
several children. She was delivered by the natural efforts 
without difficulty, and continued to progress favorably for 
the first week, when, without any apparent cause, peri- 
tonitis and fever supervened, and terminated fatally four- 
teen days after her confinement. 

The fourth case of peritonitis was in the mother of 
several children. After a favorable labour and delivery 



by the natural efforts, she caught 



without 



any 



I 



apparent cause, which produced peritonitis and fever, from 
which she died on the eleventh day after her confinement. 
The fifth case of peritonitis was in a case of a woman 
with a very contracted pelvis, who had upon a previous 
occasion been delivered with the forceps, but not without 
much difficulty, of a stillborn child. In this her second 
labour there was even greater difficulty, in consequence o£ 
the extreme size of the head, but delivery of a living 
phild was ultimately effected, but not without considerable 



STATiSTICS OP HIDWIPERY IN PRIVATE PRACTICE. 15? 

injury to the vaginal passage. Peritonitia supervened on 
the third day, and terminated fatally on the eighth day 
after labour. In this case, as the result proved, it would 
have been more advantageous to the mother had the per- 
forator been used instead of the forcepa. 

There was a considerable interval between each of these 
caseS] and no suspicion could be entertained of their being 
caused by contagion. 

Of the two cases of advanced hoart diaease and dropsy, 
the first was in the person of a mother, aged about forty, 
who had previously given birth to several living children. 
Her labour was natural, terminated without difficulty, the 
after-birth removed, and everything seemed satisfactory. 
When I was about to leave the room it was observed that 
she breathed with difficulty, syncope soon supervened, 
from which no eftorta could recover her, and she died 
within two hours after the termination o£ the labour. The 
uterus remained perfectly contracted, and there had been 
no htemorrhage. The second case, of heart disease, had 
been confined fourteen days, and was in a fair way of 
recovery when death took place suddenly from syncope. 

One death appeared to result entirely from fright. A 
primipara, aged about twenty, had been confined 
without difficulty two days previously to a violent thunder 
atorra passing over the city. She was of a very nervous 
temperament and was much alarmed. Hysteria super- 
vened, followed by exhaustion, from which she could 
not be rallied, and died four days after delivery. There 
bad been no hfemorrhage or other untoward symptom to 
account for her exhaustion. 

The case of cancer of the tongue was of a very distress- 
ing character, as it had been impossible to odminiBtor 
food by the mouth for several weeks previously. She was 
^B the mother of several children, and aged about forty, 
^H Her exhaustion was so extreme that delivery required to 
^H be effected with the forceps, by which a living child waa 
^^m bom. The mother died fourteen daye after delivery. 
^^M The case of bronchitis was in the mother of several 



158 STATISTICB OF MIDWIFBEY IN PBIVATH PEAOTICK. 

children. She was about thirty years of age, and was 
delivered by the natural efforts of a living child. The 
bronchitis had existed for several days previous to- the 
commencement of labour. She died four days after her 
coufinement. She belonged to the poorer class of inha«_ 
bitants, and probably did not obtain sufficient nourish- 
ment to sustain her powers. 

The case of scarlet fever was in the person of a mother I 
of several children. She was between thirty and foriy I 
years of age, and had not previously been afflicted witbl 
the discose. She was evidently infected by the dii 
her own family at the time. The first symptom of I 
disease appeared on the fifth day, and terminated fatal 
on the tenth day after her confinemout. Only one othgj 
case of this disease at or about the time of labour ha^ 
occurred in my practice, and this woman recovered. 

Two women were attacked with variola in a modifier 
form after vaccination at the period of their confinementa.l 
they convalesced, however, favorably, and were reporte^j 
with others of a similar character, in the ' British Medict 
Journal' for February, 1877. 

I have no record of cases of measles occurring at t 
period of parturition. 

There is no doubt bat that many of the above midwiferi 
cases occurred during epidemics of these diseases, to whio 
the mothers must have been to some extent exposed, 1: 
their immunity was probably due to their being protectfl 
by having gone through the disease previously. 

In three only of the maternal deaths were the ' 
delivered by the forceps or any other instrumental assia 
ance. The first case of petitonitis was delayed too 1 
before the forceps were applied. The fifth case of perito 
nitis would probably have terminated more favorably f 
the mother if the perforator had been used instead of i 
forceps, but in this case it was impossible to obtain 
second professional opinion, without which, unless t 
child is known to be dead, one is naturally reluctant t 
iufiict so serious au injury upon it. In the case of c 



STATISTICS OF MIDWIFEET IN PBIVATB PRACTICE. 159 

of the tongue, the forceps were moat urgently needed, and 
the mother must have died andelivered but for their 
assistance. 



Dr. Edib thoueht great credit was due to Mr. Bigden for the 
exceedingly small maternal mortality — only 13 out of 5682 
deliveries. It was curious to note that the proportion of still- 
births did not vary with the change from ergot to forceps. In 
the first 2000 cases of delivery the forceps was only employed 
nine times, whereas in the last twenty years it had been used 
260 times, or once in every fifteen cases. Mr. Rigden hazarded 
the remark that forceps had not increased the infant mortality. 
Dr. Edis believed that the judicious and timely application of 
forceps seemed to diminish materially both the infant and 
maternal mortality, more especially in large cities, where so many 
defective hygienic surroundings tended t« deteriorate the general 
health and lower the standard of vitality. The time for discus- 
sion being so limited. Dr. Edis would not take up the time of 
the Sodety with any further remarks. 

Mr. Rigden, in reply, stated that the infant mortality was 
rather less in the aeeond than in the former period, but the more 
frequent use of the forceps during the second period resultt^d in 
very great advantage to the mother by diminishing her suffer- 
ings and expediting her convalescence. 



JUNE l8T, 1881. 



I 



J. Matthbws Dcncan, M.D,, F.R.S. Ed., in the Ch&ir. 

Present — 35 Fellows and 5 visitors. 

Books were presented by Mr. T. M, Dolan, Prof. G. 
Ercolani, Dr. Vincenzo Maggioli, and Dr. James Murpty. 

Jftmes H. Jeffcoat, M.R.C.S. (Fort Pitt), was admitted 
ii Fellow, and Thomas Hopcroft, M.R.C.S. (Derby), and P. 
B. Tnthill, M.D. (Fort Pitt), were declared admitted. 

The following gentlemen were proposed for election : — 
James Alexander Close, M.B. (Illinois), and James Gideon 
Creasy, M.a.C.S. (Brasted, Kent). 



DEPRESSION OF CHILD'S HEAD BY FORCEPS. 

Db. Godson presented a cast of the child's head, showing 
a depression after delivery by forcepH, which he bad shown 
at a previona meeting of the Society. 



HISTOLOGy OF CANCER OF THE BODY OF THE 
UTERUS. 

Dh. Galabih showed microscopic sections from two cases 
of cancer of the internal surface of the body of the ntema, 
illuBtrating the commencement of the disease in the form 
of cylinder-epithelioma, which, later on, merged into 

TOi~ zxni. 11 




162 msTOiooT OF cahcsb ot thb body op THB tmBOB, 

medullary carcinomE, The tissue in both caSi 
removed by curette. The first patient was a married 
woman, forty-eight years old, mother of four children, and 
had suffered for six months from constant metrorrhagia. 
The uterus was quite movable and but slightly enlarged ; 
the cervix was affected by ordinary granular inflammation 
only. The sections showed tissue differing but slightly 
from the mucous membrane of the body of the uterus. 
The glands were proliferating and divided its compart- 
ments by upgrowth of processes from their walls. In 
several places this upgrowth of processes gave rise to the 
appearance in the sections of one circle or tube of epithe- 
lium within another. A still more decisive evidence of 
malignancy was given by the occurrence in one or two 
places of groups of epithelial ceils in the stroma. The 
second patient was a virgin, aged fifty, who had had metror- 
rhagia for more than a year. The uterus was fixed and 
nodular externally. In this instance the glandular 
arrangement of the cells was still evident in many parts, 
but much less regular, and the stroma was infected by 
many epithelial masses, in which the glandular appearance 
was lost. He had found cancer of the body of the uterus 
relatively not uncommon in virgins, while he had hardly 
ever met with the ordinary cancer of the cervix when 
there was evidence of virginity. 






Dr. WiLTSHiBB thought the matter important in reference to 
the removal of such growths from the mterior of the uterus ; 
and he related particulars of a case he had seen in consultatioa 
with Mr. E. White and Dr. Braxton Hicks, in which, after 
thorough removal of the malignant growth and the use of 
perchloride of iron, the patient, a lady sixty years of age, lived 
three years all but one month. Cancer of the body of the 
uterus were of tun obscure, but when diagnosed, thorough 
removal was desirable where practicable. 

Dr. Cleveland ventured to hope the time would come when 
such an exact diagnosis of the disease in its early etiige might 
be established as to warrant ri^course to more radical measures 
than had been carried out by Dr. Wiltshire. He thought that 
even the risk attending the entire removal of the uterus might 
be preferable in well selected casee to the distressing Bymptoma, 



I 



CIBHO-VAQINAL EDPTUEE. 



of the n 

Dr. Hetwood Smith added lus t^etimoay to Dr. Qalabin's 
as to cancer of the fundus occurriMg more frequently in virgina. 
and cited the case of a lady, aged fifty, who was the sulject of 
cancer of the body of the uterus where the cerrix waa healthy. 
He considered that where such cases could be diagnosed 
sufficiently early, the uterus should be removed, leaving the 
healthy cervis as a stump. 

Mr. Coras insisted on the importance of recognising the fact 
alluded to by Dr. Oalabin, that cancer of the cervis uteri vras 
almost peculiar to impregnated women; since it is amon^ such 
that we likewise find so frequently the numerous forms of " ero- 
sion " of the oa estemum, once called ulceration. Through the 
observations of Sir James Paget and Mr. Butlin, pathologists 
had become aware that a disease of the nipple closely simulating 
eczema is a frequent herald of scirrhus of the breast. Protec- 
tion of the inflamed patch of integument and the application of 
simple cooling lotions often cured this eczematous affection, 
which otherwise might have developed, more or less directly, 
into scirrhus. It is very necessary, therefore, to examine most 
carefully any obstinate erosion or granular patch in the neigh- 
bourhood of the OS externum, and to attempt t« establish a 
distinction, if there be any, between simple erosion and the 
form which precedes cancer. The cure of such a form might 
absolutely avert malignant disease, and such a cure involves the 
most peifect possible protection of the ^rt from the irritation 
both of morbid diachai^s and of irritatmg applications. 



SPECIMEN OF UTERO-VAGINAL RUPTURE :— 
PLACENTA PREVIA, MULTIPLE FIBROIDS 
WITH DEFORMED F(ETUS. SO-CALLED CRE- 
TINOID. 

De. WiLTSHiBB showed specimeiiB as above, from a case 
which occurretl in the Maternity Department of St. Mary's. 
It was her ninth pregnancy, and a week before, patient fell 
over one of her children — an idiot. On the arrival of a 
student placenta was found iu vagina, with much hemor- 
rhage. The obstetric honse-snrgeon delivered speedily the 
head, which was low down, the placenta having already 
previonBl; been expelled spontanoonsly. Hsmorrhage, 



164 



CYST OF THE QBEAT OMENTUM. 



however, contiuned, and when Dr. Wiltshire visited the 
patientj shortly after delivery, she was rapidly sinking. 
Post mortem the lacerations shown in the specimeii were 
foand, together with many small fibroids, and the utems 
was very large and thick. 

Dr. Hkywood Smith would remind the Societj of two cases 
which Dr. Wiltshire and he brought forward some time ago, 
where rupture took place in his case, with placenta pnevia, at the 
passage of the head, where no instruments were used, and both 



i 



C7ST OF THE GEEAT OMENTtTM. 



\ 






Mb. Alban Doran exhibited for Dr. Bantoce a lai 
thick-walled, single cyst, removed from a woman, 
58. For many years she had suffered from symptoma 
resembling those of cystic ovarian disease, and two years 
before operation the cyst had ruptnred and filled again. 
She had been tapped several times by Mr. Goodall-Cope- 
stake, of Derby, dark serous fluid being removed. On 
May 28th 1881, Dr. Bantock operated, with the assistance 
of Mr. Doran. A large cyst was found, very intimately 
adherent near the umbilicus to the parietal peritoneum ; 
the adherent tissues were much thickened and calcified. 
The abdominal wound bad to be extended, owing to great 
difficulty in separating the tumour from its connections; 
when this was done tbe relation of the cyst to the peri- 
toneum was found to he as follows : — The great omentnoi 
was normal from the greater curvature of the stomach to 
its usual adherence to the transverse colon, but could be 
traced as a thickened and calcified sheet on to the top of 
the cyst, which proved to be entirely within the omentum, 
for that serous membrane passed partly in front of the cyst, 
then hung as a characteristic fatty and membranous mass 
from the lower border of the cyst, and thence passed upwards 



CyST OF THE GREAT OMENTOM. 165 




Dr. B«ntock'i esMt ot ejit of tho great oTnciituni, showing the dupotition 
tbe poritoncam u discovered daring the operation. 



.. Omontum between tlomach anil transvene colon (Dormol). 

!. Omentmn, tram its normal adlieuon to eoha to tbe ejit (moch 

thickaned and putly okareoui). 
I. Intimate adheiioD of parietal peritoneani, omentum, and cjit-wall. 
k Deicendinglajenofomentnta, adherent to eytC and itueparable 
>. LoHcit part of omeDtom, almiMt nonoftl, and not adherent to 

pelvic peritoDonm. 
i, AicsndinB lajsr* of omentom, sdherfot to ryit, and inseparable. 
'. Meseiitfrv purtl^rxlherenttoomsDtnmbrMndcjn. Itcompletelj 

eicludt'd tlie cj<t from the pelvic peritoneDm and arjnnii, 
I. AMending layer* of omeutom (imeparable) g^oinfr to divide in 

front of colon, to form— 
I. Trwuverae netocolon (nomal, hot alii^htlj adhiTent to 6) i 
>. Parietal; and — 11. Pelvic peritoaeum, 



166 



MAHBP*T.T, B PATENT 8KCTI0»AL rEIDHTO BOTTLE. 



over tbe bock of the cyst, luiitiiig firmly at the c 
limit of the tumoar with the front portion of the omentum, 
continuouB with the part deecending from the colon and 
atomach, A fold of mesentery completely separated the ■ 
tumonr from the pelvic organs, where the ntems, ovariea> J 
tahes, and peritoneal folds were absolutely normal, Th» 
tnmour was partly adherent to this fold of mesentery aodl 
to the transverse mesocolon. A drainage tube was ;" 
sorted for twenty-four hours, and the patient, four days J 
after the operation, was progressing very favorably. 

To illustrate this rare affection, Jlr. Doran also exhibited | 
aHuuterian specimen (No. 1109, Pathological Series, Mus, 
B.C.S.), to which no clinical history was given ; it showed 1 
very clearly a small cyst entirely in the folda of the g 
omentam. 

The diagram explains the relations of the cyst in Dr. 1 
Bantock's case, as detected in the coarse of the operation,] 



MARSHALL'S PATENT SECTIONAL FEEDING -1 
BOTTLE. 



Db. Godson showed a new feeding bottle, possessinff 
the advantage of having a movable front, enabling the '. 
fingers to be introduced and reach readily the whole inte- 
rior for cleansing purposes, thus obviating the use of the 
bottle brush. These bottles would shortly be retailed, at 
about one shilling each, under the name of " Marshall's 
Intent Sectional Feeding Bottle." 



NOTES ON A CASE OF PLACENTA PRjEVIA COM- 
PLICATED BY A LARGE MTOMA. 



By J. HlCKINBOTHAMj M.D., 






The following case illastrates certain important facts in 
uterine pathology ; and it presented unusual difficulties 
both as regards diagnosis and treatment. I therefore 
think that my notes will be of interest to obstetricians. 

At noon on tho 12th of March, 1S80, I was called to see 
a yonng lady of small stature and extremely delicate 
appearance in her Brst labour at term — she had previously 
aborted. The gentleman in attendance told me that she 
had been in labour about six hours, and bad lost a con- 
siderable amount of blood. He had recognised the case 
as one of placenta pnevia. 

The patient's condition was somewhat alarming ; there 
had been several gushes of hajmorrhage, which had left her 
face pale, and her pulse feeble and quick. An exami- 
nation showed the os uteri large enough to admit two 
fingers, and very soft and dilatable. The placenta pre- 
sented completely, no edge conld be reached, and its 
thinnest part aeeraed to be in the middle; through this I 
could feel a ronnded mass, which I supposed was the fcBtal 
head. 

The patient was placed under chloroform and the oa 
dilated, but 1 was still unablo to find the edge of the 
placenta, and therefore decided to break through ita 
substance in the central thin part, push back tho head, 
seize a foot, and deliver as rapiflly as possible. When, 
however, I had torn my way through the placenta, I dis- 
covered that the hard round mass, which had been taken 
for the foetal head, was a large tumour, upon which the 
afterbirth was uniformly attached. With a good deal of 
tronble I got my fingers between it and the pubis, and 



168 rUCOTA FBXVU COMPLICATED BT A LABGB HTOKA. 

reached a shoalder. The extreme difficulty of this * 
manoetiTTe conviiiced me that any attempt to save the 
child would be utterly useless, and I therefore completed 
the delivery of the placenta, after which the hieniorrhage 
greatly abated. I now inserted two fingers of my left 
hand, and with my right upon the abdomen, managed to 
seize a foot, and eventually succeeded in getting down the 
body. Ab the head resisted all the traction I deemed it 
prudent to employ, I passed a perforator and pierced the 
cranium throngh the occipital bone. 

The space between the tumour and the pnbes was too 
email to admit any form of forceps, so I used a small 
crochet, and having obtained a purchase, by carefoUy J 
pulling upon it whilst my friend pulled the body, ■ 
managed to extract a email but perfectly formed child. 

A terrible attack of septicEemia followed, and tor a fort-V 
night I almost despaired of the patient's life. She h&dl 
high temperature, quick, feeble pulse, and profuse offensive 1 
discharge. No milk was ever secreted. From the first, 
intra-nterine injections were gently and carefully used as 
often as three and four times a day. Ergot, sulpho- 
carbolates, and quinine were administered in full doses, J 
and nutrient enemata given nntil the stomach was abl9>l 
to retain food. 

I soon became aware that the tumour was sloughing", 
and an examination four days aft-er labour showed that ic 
was, to a large extent, extruded through the os. Being 
unable to find anything like a pedicle, I painted the whole 
of the presenting surface with pure carbolic acid and gave 
an opiate. The next day she was markedly better. 

On the tenth day I was able to hook down and cxtracfe J 
a mass, the size of a small orange, soft, easily broken up, I 
and horribly fetid, but still thL-re was a tliick stump! 
filling the dilated cervix; to this I applied carbolic acid. I 
Two or three days after I was not able to detect any I 
remnant of the tumour, and the oa uteri was entirely | 
closed. In three months the uterus was freely mobile 
and its cavity of the normal length. 



I 



PLACENTA PREVIA COMPtlCiTBD DY A LAROE MYOMA. 169 

The patient called upon me yesterday (Feb. 22nd, 1881) 
and tells me that she has never menatraated since her 
confinement, but has felt tolerably well. She has not 
regained her colour, but loots sadly anaemic ; however, 
as she is able to take long walks, and eats and sleeps well, 
I trust that her recovery will soon be complete. 

The case is interesting, both in pathology and treat- 
ment. That a placenta should be attached over a tumour 
in the posterior wall of the aterua, and also completely 
involve the os, is a condition which, as far as I know, has 
not been described. 

With regard to treatment, it is difScnlt to make up 
one's mind. Had the presence o£ the tumour not been 
masked by the placenta (or, in other words, had the 
placenta been normally placed) so that the relations of the 
tumour could be made out, I should assuredly have 
preferred to perform abdominal section, both for the sake 
of saving the life o£ the child and of preserving the mother 
from the almost certain dangers of septicffimia, which would 
follow the inevitable injuries to the tumour. 

But with the placenta prtevia, and partially detached 
from the surface of the tumour, I felt (and still feel) that 
I adopted the better course in endeavouring to complete 
the delivery per via« naturales. 

The result is gratifying in that the tumonr has been 
cured, as well as the life of the woman saved. 

Dr. Baknks obBerred that no general rule could be laid down 
for the man^ement of labour complicated with fibroid tumours 
of the uteruB. The conditions varied so much that we must be 
^vemed by the estimate formed at the time of the nature 
of the ca«e. The complication was always dangerous ; even 
when the tumour waa seated at the fundus, not obstructing the 
transit of the ctuld, the tumour might fall into necrosis and 
cause septicranda. Occasionally the tumours would shrink after 
labour i of this he had recently seen an example. Occasionally 
they would undergo necrosis and spontaneouB enucleation, and 
tliuB end well. In the presence of labour obstructed by a tumour 
in the lower segment of the uterus, we may in some cases, after 
dilating well, push tbu tumour out of the way and deliver after 




170 



OH THX 80-CALt«> " LITHOPiDIOH." 



cnmiotomy, or by taming. Enuckatiou might be available, bat 
in extreme cases it might be necesaarj to resort to Cfesariaa 
section; and in sach cases it ought to be conndered whether it 
would not be bett«r both for the immediate and fatnre wel&jie 
of the patient to carry out Porro'a operation, that is, to remove 
the whole uterus with ita tamoor. 

Dr. HicKisBOTHAJi said that the size of the tamour, and 
especiallj its wide base, forbade the possibility of enacleatioti. 
Moreover, he had a great dread of septic poisonins^ after the 
enucleation of myomata. With reference to the remarks of Dr. 
Barnes, he was glad to find that he agreed with him as to the 
adTisability of the Cssarian section, but he would hesitate to 
follow it by extirpating the uterus itself, as the results of the 
operation seemed to him very unsatisfactory ; and he b^ered 
that all the advantages to be obtained by such removal could 
be ensured with far less risk by the removal of the ovaries and 
tubes, which would ensure future sterility, and most probably be 
followed by shrinking of the tumotir and immediate enppressioa 
(rf luemorrhage. 



I 



NOTE ON THE SO-CALLED " LITHOP^DION " 
BEING A SUPPLEMENT TO THE AUTHOR'S 
PAPER ON SO-CALLED "MISSED LABOUR." 



By EoBBHT Baekb8, M.D. 

In the discasBion on my paper on " Missed Labour " 
two points arose which appear to demand and to admit of 
further elucidation. The first relates to the nature of the 
BO-called " Lithopcedion." The second relates to the 
occurrence o£ " missed labour " in the lower animals. 
If we ask what ia meant by the term " lithopjedion " and 
accept for reply the etymological meaning, a " stone- 
child," we have next to ask for the production of a specimen 
which fairly makes out its title to this designation. As 
I took occasion to observe, a " stone-child " should at least 
be " stony." Hence we mast at once exclude tho ordinary 
specimens of mummified and adipoceroos embryos, as these 



I 
I 



I 



ON THX SO-CALLED " LIT HO Pi: DION." 17] 

do not exhibit any calcareous ctaDge. The mummifying 
and adipocerous changes are those which commonly take 
place when the embryo is retained in utero for some 
months after its death. Perhaps the moat typical 
examples are seen in those cases of twin pregnancy in 
which one embryo dies at an early stage, the other living 
on to fail development when both are expelled. 

Cmveilhier's dictum that the stone- con version never 
takes place in utero is still unchallenged by facts. And 
now the question arises : Does the embryo ever undergo 
the stone- conversion nnder any circumstances ? All the 
cases of so-called " lithopfedion " have been found outside 
the uterus. The historical case of Dr. Cheston, described in 
the ' Medico-Chirurgical Transactions,' 1814, is undoubtedly 
one of extra-uterine gestation. This specimen (prepara- 
tions, Nos. 2720, 2721, and 2722) in the Hunterian Miisenm 
I have examined, and by permission of Mr. Flower it has 
been minutely examined by Mr. Doran, who has favoured 
me with the following report : — '* The abdominal viscera and 
thoracic organs are all quite soft but impregnated with 
lime-salts. The integuments and subcutaneous tissue of 
the front of the thorax and abdomen are very thick and 
infiltrated with Ume-salts so as to feel gritty and friable. 
The integument and subcellular tissue of the 'posterior 
part of the body are very thin and converted into hard 
calcareous plates. In short, calcification is most advanced 
posteriorly, least anteriorly." 

It deserves to be noted that although this case has often 
been cited as an example of missed uterine labour, it is 
not so described by Dr. Cheaton, nor by Sir Wm. Lawrence, 
who presented the specimen to the College of Surgeons. 
Lawrence's mind did not lend itself readily to the reception 
of the marvellous ; and the title of Dr. Cheston's memoir 
reveals philosophical caution ; fhe title runs : " The history 
of a child retained in the mother fifty-two years after the 
usual period of utero-gestation," but he nowhere says that 
it had been retained in utero. Indeed, he describes the 
. otems as " though diminished in thickness, as still retaining 




172 



OS THl BO-C&LLED " UTHOPSDION," 



Eomewhat of its natural strnotore ; the Fallopian tabes were 
healthy, the ovaries were not fonnd." It was, therefore, 
in all probability, an example of abdominal gestation. The 
preparation 2721 is a portion of the " osseous cyst in which 
an arm and leg are tightly impacted and adherent to ita 
walls. The waUs of the cyst are a line in thickness and 
appear to be composed of true bone," This last statement | 
no doubt requires correction ; the condition is rather calci- 
fication. " The skin (preparation 2720) was in many partg 1 
adherent to the interior of the cyst and was torn in 
separating them." (Catalogue Hnnterian Museam.) 

Another specimen in the Hunterian Museum, No. 2719, 
is especially interesting. It presents the closest apparent j 
realisation of a stone-child. It is a dry preparation. It I 
is described in the catalogue as " a fcetns almost com- 
pletely developed, but compressed and dried so that little j 
more than the bones remain to indicate its previoas form.'' 
There is no history of the gestation, and the fcetua does ! 
not appear to me to have exceeded seven months' deve- 
lopment. Mr. Doran gives me the following report upon 
it : — " It is a skeleton much contracted, with the soft 
parts shrunken and calcified. It is this contraction of 
the hardened integuments on the boHes that causes the 
entire ftetns to appear actually stony. If it be touched 
with a sharp-pointed instrument at any one point, whether 
on the cranium, trunk, or extremities, that point will be . 
found to be brittle, and by no means remarkably hard. 
It represents an extreme degree of the condition seen on 
the dorsal integuments only of the specimen No. 2720. 
The calcification of the periosteum gives the bones their 
peculiarly stony feeling." The lungs are powdery and J 
effervesce with hydrochloric acid. 

In St. Thomas's Hospital Museum is another remark- 
able specimen, which was sect to me by Mr. Watkins, and I 
exhibited to this Society (see 'Obst. Trans.,' vol. viii). 1 
This foDtuB had been retained forty-three years in the I 
abdomen. The following are the facts made out by I 
myself and Mr. Stewart : — It has all the appearance of ai^ J 



I 



I 



I 






ON THE SO-CALLED " LITHOPSDION." 173 

embryo which had reached full development. It is 
doubled up and compressed into a ball, enveloped in a. 
sac, which fits so closely to its limbs, trunk, and head, 
that no more than the general outline of the parts could 
be made out. This envelope consists of the cyst wall and 
the chorion and amnion, and it has very generally under- 
gone adipocerous and cretaceous metamorphosis, so that 
the mass looked at snper&cially might pass for a stone- 
child. But when we come to peel off this envelope we 
find that even this is only partly calcified ; it can be 
peeled or dissected off the surface of the child as a 
flexible membrane, having many calcareous plates in it. 
In some places it is so intimately adherent to the child'a 
skin that it can hardly be separated from it. In these 
places, especially the skin, is also marked by calcareous 
deposits. But stili the akin itself can bo dissected off 
from the deeper tissues as a Sesible membrane, and is in 
many places apparently little altered. The scalp is in 
many places calcareous, and the pericranium is also 
hardened, but it can be detached from the cranium. The 
brain is soft, of a dark brown colour. The thoracic and 
abdominal viscera are soft and easily recognisable; and 
the muscles generally are little changed, they retain 
nearly their natural colour. Between the investing 
chorion and skin one makes out the vernije cascosa as 
having undergone calcareous metamorphosis. There is 
general more or less hardness of the specimen from loss 
of fluid, and special hardness in parts from cretaceous 
change. 

The following facts result from the examination of 
these specimens: — Ist. That the chief process of calcifica- 
tion takes place in the cyst walls and foetal membranes. 
2nd. That in a minor degree calciBcation takes place in 
the integuments of the ftctus, which in part coalesce in 
calcification with the envelopes and cyst walla. 3rd. 
That the deeper structures of the foetus, including the 
viscera, become more or less impregnated with lime salts^ 
withont, however, becoming hard or stony. 



174 



OH THE 80-CALIJD " LITHOPiMON," 



From these facts, and from the application of known 
.laws in the history of degeneration and metamorphosis, 
we may infer that : 1. There is no reason to doubt that 
the tissues of a dead fcetus long retained in the mother 
may become infiltrated with calcareons matter. We are 
familiar with calcification of the arteries, of fibroid 
tumours, of the placenta, and of other structures during 
life, 2. The more frequent change of the fcetus after 
death is certainly the adipocerous ; and we require further 
evidence to justify the conclusion that calcification takes 
place in the tissues of the retained fcetus to more than 
a very limited and superficial extent. The superficial 
and partial calcification of the integuments was chiefly 
observed at points of contact and even of intimate adhe- 
sion with the cyst walls. It seemed, in fact, to be 
secondary npon, and to have arisen out of the previous 
change in the envelopes. It is now very well known that 
the placenta and chorion are especially prone to undergo 
adipocerous and calcareous changes. These changes I 
studied very carefully and described in the 'Medico- 
Chirurgical Transactions.' They may take place dnring 
the life of the organ. Thus I have seen not only multi- 
tudes of calcareous points and patches, but in some cases 
large portions of the placenta quite atony when the child 
was born alive, 3, It seems probable that the process in 
these cases of apparent fa?tal calcification is, first, the 
death of the fcetus ; secondly, the calcification of the 
envelopes and sac walls ; thirdly, the partial change of 
the fcetas into calcareous matter, but never amounting 
to stone hardness, as in the case of the envelopes ; this 
hardening being prevented partly, at least, by the pro- 
tection against removal of the fluid elements of the fcetus 
by the closeness and density of the investing calcareous 
shell. 

From the examination of these specimens, then, it ia 
established — 1st, that it is not correct to say that the cal- 
oification is limited to the membranes and cyst-walls j 2nd, 
that caloificatlon may extend to the proper tissues of the 



JL 



ON THJC BO-CAUiID " LIXHOPfiDIOS." 



175 



fostuB ; but 3rd, that this extension is but partial and 
superficial, njaialy limited to the skin. 

A litbopfedion, then, has at present no more than a 
potential or ideal existence. There may be reason to 
think that conld the fgetus be retnined long enough in 
BDch circumstances that the deep structures could part 
with their moisture, these too might become calcified. 
But this can hardly happen. Dr. Cheston's foetus was 
retained fifty-two years and Mr. "Watkins's forty-three years. 
It is not likely that, as far as time is coiicemed, the process 
of calcification to the point of producing a. solid stone-child 
will ever have better opportunity of being completed. 

I now offer a tew remarks upon the supposed missed- 
labonr in cows and ewes, and upon the analogical applica- 
tion to the theory of missed laboar in woman. 

In the Hnnterian Museum are several interesting 
specimens in this connexion. 

No. 2725 is " the os uteri of a cow whose uterus had 
contained twin calves for nearly two yeapB." The speci- 
men and the history are too imperfect to justify any 
conclusions. 

No. 2726, "portion of a horn of uterus of a sheep, 
containing head and a foot of a lamb which had remained in 
the utems beyond term and became adherent to sur- 
rounding uterine wall." 

It may be doubted whether this and similar cases carry 
the evidence of protracted retention of a foetus which had 
lived to the full term in ulero in lower animals further 
than the evidence we possess of the same process in woman. 
The subject certainly deserves further investigation. 

And supposing that " missed labour," in the full 
meaning of the term, bo established as occurring in the 
cow and ewe, there is one consideration which should mako 

I us cautious in applying the argument of analogy lest we 
overstrain it. There are remarkable differences in the 
structure of the uterus in the cow and ewe and in woman. 
Even if we regard the horns of the ntems of the mminant 
fts the homologne of the boms of the human uterus, deve> 



I 



IS 

loped and tong di«wii oat so &s to hold the embryo, we BtSl 
canuot help eeeing that gestatioB in these hems is reiy diff- 
erent from gestation in the ntenis proper of Uie woman. To 
prore that a raatvre Ecetns may be indefinitely retained 
ia the horned ntems of a cow will not satisfy the physio- 
logist that the like event may happen in woman. Withont 
comparing the normal hom-gestation of the ruminant to 
the abnormal Fallopian gestation of woman, there is enoo^ 
to suggest the idea that both are forms of tubal gestation. 



The PBESTDKXt said that th« paper sminglj impressed him 
with the neceaaitj of greater carefulness than he and other 
authors had used, in applying the word lithoi^isedion. The obser- 
ratioDB made, especially in the Hunterian Museum, confirmed the 
remarks he made when Dr. Barnes's original paper was read, that 
there was never a stone-child really, but otdr petrification of the 
membranes and adjacent fcetal parts. The condition of the 
deeper parts was a valnable part of the obserrations now given 
to the Society. 




I 



JULY 6th, 1881. 

J. Mattbbws Dcncan, M.D., F.B.S. Ed., President, in the 
Chair. 

Present — 32 Fellows and 3 risitors. 

Books ware presented by Dr. Henry W. Aokland, Dr. 
Thomas Addis BuiQiet, and the Smithsonian Institution. 

Dr. Joseph Johnston and Mr. Julian Willis were 
admitted Fellows of the Society. 

James Ales. Close, M.B. (St. Clair co., Illinois), and 
James Gideon Creasy, M.R.C.S. (Braated, Kent), were 
elected Fellows of the Society. 

Herbert George Cronk, M.B. Cantab., John Mill 
Frodsham, M.D. Ed., and Charles S. de Laoy Lacy, 
a.A., M.B. Oxon., were proposed for election. 



Db. Fahcoubt Basnbs showed an instrument designed 
by Dr. C. Duncan, of Rome, to measure the amount of 
flexion existing in anteilexiouB or retroHexions of the 
\ atems. 

TOL. XXIII. 12 



ANENCEPHALOn) FCETUS. 

Db. Popk sbowed an anenccphaloid fcetas. The 
was intereBting as the monati^r was one of twins, and tli6 
labonr itself presented some features worthy of note. 
The mother was in the eighth month of pregnancy, and 
had slight pains in the abdomen all day. On examination, 
a process of the membranes like the finger of a glove, 
and containing liquor amnii only, was foand projecting 
from the vulva. This was raptured, and a second bag of 
membranes could then be felt projecting from the os 
uteri. When this was raptured an arm and piece of fanis 
came down. A foot was seized, and the anencephaloas 
child was soon delivered alive. A foot of the second 
child was then reached and the child removed as far as 
the neck, when the os nteri closed hrmly on the head. 
By inserting a linger within the mouth of the child the 
chin was depressed, forming the apex of a wedge, which 
soon dilated the os and allowed the delivery to be effected. 
The placenta was single and the monster lived eighteen 
hours. It is to be noted that the mouater was bom £rat. 



Dr. Godson showed for Dr. Ceonk 



foUow 



specimens : 

I. A UA^LFOKUHD HBABT With aorta arching over 1 
right bronchus, and pulmonary artery closed at or abod 
the semilnnar valves, The specimen was taken from i 
male child at full term, who died, fifteen days after birth,) 
from an acute attack of chronic hydrocephalus, 

Tlie patient was noticed to bo very cyanoeed at bir 
and for a dtiy or so afterwards; the lividity then ( 
penred and did not return to any marked degree. 

Th» heart. — Eight auricle dilated, foramen ovala^ 



MAL?0R1IBD HBAST. 



179 



patent but closing. Left auricle admitted the pulmonary 
veins, but was amaller than natural. Ventricles of nearly 
equal size and thicknesB. The upper part of the luter- 
Tentricnlar septum was absent, the ventricles thus opening 
into each other and into a common vessel — the aorta — 
which was closed by three semilunar valves, quite healthy, 
and behind the two anterior were the orifioea of the 
coronary arteries. The remains of the pulmonary artery 
consisted in a prolongation upwards from the right 
ventricle, and a tube which opened above into the aorta 
but was separated from the infundibulum below by » 




I 



.emWanons septum, above which were three depressions 
marking what should be thoaituationof tbepulmonary semi- 
lunar valves ; but no trace of these was present, unless 
the septum were formed by their adhering together. The 
aorta ascended for three quarters of an inch, and then 
bifurcated, the larger braucli arching over the right 
bronchus, passed downwards and backwards to gain the 
right side of the vertebral colomn, and then crossing over 
the bodies of the vertebrte, pierced the diaphragm at its 
usual situation, it gave off the followiug branches : — 
Bight common carotid and right subclavian, and then 



180 



BUllOICAL POCKET CASK. 



the aortic intercotdtalB. The smaller branch of bifurcation 
urclietl over the left bronchus, giving off the left com- 
Bion carotid ftod left sabclavianj and then continuing 
onwards bifurcated on the trachea, each division Bubdiyid- 
ing into numerous branches which entered the root o£ 
each long supplying it. There was no tranBpoaition of 
any of the viecera. 

The diagrams illustrate the mode of development of 
the alteration in the great vessels. No. 1 shows the 
normal development of the aorta and great vessels. 
No. 2 showe the change that occarred in this case, and 
the probable mode of ita development, 

2. As UllBIUCAL CORD IN A BTATK OP CTSTIC SEOENB RATION. 

— Placental portion of cord healthy. Fistal portion for 
twelve inches enlarged, five inches in greatest circam- 
fcreuoe. On section presented its nsnal constitaents. 
Wharton's jelly in excess and occupied by large cysts, 
crossed by soft trabeculie, and filled with a clear, trans- 
parent, viscid fluid, which readily flowed out; the cysts 
did not communicate. 



SURGICAL POCKET CASE. 



Db. Godson showed, for Mr. Arnold Thompson, of 
Ampthill, a surgical pocket case designed by him for the 
purpose of enabling surgeons and general practitioners to 
have a portable and compact set of really useful and neces- 
sary instruments to be carried during the daily round of 
visiting, as well as when sent for hastily to an anknown 
case. It contains over two dozen foil-sized and efficient 
instruments, via, : — Clinical thermometer, cansttc case, Cor- 
rigan'a actual cautery button, director, Bellocq's epistaxis i 
cannula, finger saw, eiploriug needle with saw SttinM 
Toynbee's ear speculum (constructed to act as a tracheo- I 



BEPORT ON DE. CLEVELAND 8 SPECIMEN 



181 



I 



tomy tnbo when desired), bull-dog torccps, straight bis- 
tonry, gum lancet, Fergnson's knife and aneurism 
needle (mounted togotlier), dressing forceps, medium- 
sized silver-plated catheter (adjustable for male op female), 
silver probe, Cbesterman's patent measuring tape, hypo- 
dermic syringe (with gold needles for injection and aspira- 
tion), folding steel scissora, and Imray'a double ear scoopj 
besides compartments for lamels, discs, vaccine points, 
wire, thread, and surgical needles, lint, plaster, and oil-silk, 
&o. The case measures about five inches and a half long, 
three wide, and one deep, and is shaped like an ordinary 
cigar case. It could not fail also to be very useful and 
handy to militia or volunteer surgeons when on duty. 
Messrs. Arnold and Sons, of Smithfield, are the makers. 



REPORT ON DR. CLEVTILAND'S SPECIMEN. 



The specimen is SJ in, long, 1 in. wide, and J in. 
thick. The outer surface is somewhat rough, one end is 
rounded and closed, the other terminates by an opening 
having two smooth lips, and resembling an os nteri. 
There is a central flattened ranal about J in. wide, having 
a comparatively smooth surface. Tlio thickness of the 
walls is pretty uniformly about ^ in., but along the aides 
it is somewhat less. Microscopic sections show the tissue 
to correspond to the uterine dccidua of pregnancy. It 
abowa very large cells, especially near the surface, and 
contains wide vascular spaces, some of them occupied by 
clot. The lips of the aperture consist of the aame tisane, 
and show no cervical strnctarea. From the outer edge of 
ono lip there is a thin reflected margin, about J in. wide, 
not more than ^ in. thick, smooth on its originally free 
surface, the other evidently rough from detachment. A 
vertical microscopic section taken through the lip &&d the 




182 KON-CAPSDLATED PIBEOIDB, 

reflected margin shows the latter to be continuoos with 
the deeper layer of the deciduaj and to consiEt of similar 
tifisue, except that it is somewhat more fibrous. No 
intact epithelium is seen in any part of the specimen. 

We are of opinion that the uterae is doable, and that 
the specimen is the entire decidua from the unimpreg- 
nated side. We think it probable that the body only is 
double, the cervix single, that the smooth lips indicate the 
point at which the unimpregnated half opened into the 
other, and that the thin reflected margin comes from the 
surface of the impregnated side. 

Alprbd L. Galabin. 

Jobs Williakb. 

W. F. Cleyblasd. 



NON-GAPSULATED FIBROIDS, RESEMBLING 
RETAINED PLACENTA. 



By Jameb Bkaithwaite, M.D,, 



r TUB LEEDB BCHOOI. 



The following cases show that non-oapsutated fibroids 
of the interior of the uterus may so closely resemble 
placenta in the feeling communicated to the finger as to 
actually lead to the supposition that some placental mass 
or a portion of an oTum is retained in the uterus. This 
fact seems to me not a mere matter of curiosity only bnt 
of practical interest. 

Mrs. L — , on the tenth day after delivery, commenced 
unexpectedly to lose blood. Dr. Green, of Leeds, her 
medical attendantj found on examination what he took to 
be a mass of placenta within the uterus, although at the 
time of delivery the placenta had come away entire. He 
succeeded in separating a considerable portion of this 
mass from the anterior wall. I saw the case with him at 



IKQ RETAINED PLACENTA. 



183 



L 



point, and also at first took tlie mass to be placenta. 
It was jagged and even fringed on tho free surfacOj and, 
judging from this surface alone, hardly a doubt would 
have crossed tlie mind but that it was true placental tissue. 
In this, however, alone consisted the resemblance, for the 
growth was of much firmer consistence than placenta, and 
was in its deeper parts an integral portion of the uterine 
wall, from which it could only be detached by a consider- 
able degree of force, I therefore, as had Dr. Green, 
thought the growth might be malignant, and, but for its 
tough fibrous nature, rendering it impossible to tear or 
break it down except in the direction of the long axis of 
the uterus, should have had no doubt on this point. I 
continued the separation of the growth with some difficulty 
nearly to the fundus, but finding that it could not be 
shelled out, owing to tbe absence of any boundary 
between it and the uterine structure proper, and that I 
was getting deeper into the wall of the organ, I was 
obliged to desist, and then by means of long curved 
scissors removed the whole of the separated mass — not, 
however, in one piece, but in detached portions. I heard 
from Dr. Green that the patient made an uninterrupted 
recovery, probably thanks to the care taken to prevent sep- 
ticfemia. Dr. Barrs, of the Leedfi Infirmary, kindly made 
for me a section of the growth for the microscope, and I 
forwarded this to Dr. Galabin, who reported upon it as 
follows ; 

" The tissue seems to me to resemble what I have 
sometimes seen in soft, rapidly-growing, non-encapsuled 
fibroids — large muscular fibres, very large vascular spaces, 
tissue highly nucleated in parts, and round the vessels 
something approximating to the character of sarcoma. 
Some of the vessels show the proliferation of the inner 
coat filling up the lumen which occurs in the uterine 
tiasues of placental site after delivery. I should say there 
is no evidence of cancer, but that there may be a possi- 
bQity of recurrence." 

Case 2.— Mrs. H — , of Gildersome, neur Leeds, had a 



184 



I>ON-CAra(ILi.TB!) RBBOIDe, 



i 



miscarriage at three months ; the ovmn came away with 
great rapidity and entire. Fonr days afterwards Dr. 
Steele, of Morley, examined her in coneeqnencc of htemor- 
rhoge, and he found what ho took to be a second ovum, 
I saw her with him the same evening, and found that the 
uterus contained a ragged, fringed mass, exactly resem- 
bling an ovam. I could not separate this from the uterine 
I with the blunt scoop, which I generally use for this 
Brpose instead of an ovum forceps, but eucceeded in 

noving a small portion for examination. Next day I 
cleared out the whole, the cervix being fairly dilated by 
tents left in overnight. The mass did not separate like 
an ovum would have done, but required to be seized — a 
portion at a time — by interlocking ring forceps of some 
strength and crushed. 

On microscopic examination it was found to consist of 
very loose fibroid tissue. Nothing at all resembling cel- 
lular growth could be detected. On adding a drop of 
strong acetic acid the fibroid tissue swelled and became 
almost invisible, but immense numbers of fungoid growths 
were then seen, not being affected by the acid. They 
were distinctly circular, not in chains like micrococci, and 
bad evidently grown on stalks like ordinary fungus, for 
three o£ them were seen so growing from the same spot 
on a fibre not quite destroyed by the acid, the stalks 
diverging from the common point of attachment. They 
varied a little in size, but were about one twentieth of that 
of a blood corpuscle. No doubt they had been originally 
introduced from without, probably directly from the 
vagina, but their vast number, and the manner in which 
the whole mass was penetrated with them, shows the 
rapidity of their growth. This, however, is a point more 
of curiosity than practical moment, that to which I wish 
to draw attention being the almost exact physical resem- 
blance which the growth as a whole bore to a retained 
ovum, and it is also worth noting that in both these cases 
the growth had its origin in the placental site, but never- 
ihelesB contained no placental tissue. 



RBSEUBLIHG SSIAIMED FL&CENTA. 



185 



I 

I 
I 



Dr. Edis remarked that the case was one of great iuterest, and 
worthy o£ remembrance in more ways than one. A practitioner 
might readily incur unjust blame for leaving a, portion of 
placenta in eome case where secondary hffimorrhage occurred. 
He (Dt. Edie) had recently been consulted in a somewhat Bimilar 
case where a patient miBcarried at the fourth month, severe 
hemorrhage ensuing subsequently, and continuing for several 
days. On examination a dense rough mass was found projecting 
from the posterior wall of the uterus, about the size of a hen's 
egg. On endeavouring to detach it the growth was found to be 
firmly encapsuled in the tissue of the uterus, being, in fact, a 
submucous fibroid, and not the placenta as was at first suspected. 
In a case similar to Dr. Braithwaite'a, the exhibition of ergot 
would fail in arresting hBemorrhago. The knowledge that such 
a condition was even occasionally met with might prove a valu- 
able suggestion as to the line of treatment to le adopted. 

Dr. Herman mentioned a case which had been under his caro 
in the London Hospital, in which there was a large abdominal 
tumour, shown by autopsy to be malignant. The uterus was 
enlarged, its cervix dilated, and In its cavity there was a. growth 
of loose striugy texture. In this case the patient had, when she 
firat felt thetumour, thought herself pregnant, and a medical man 
engaged to attend her, and sent for on account of htemorrhage, 
fetding through the patulous cervii the loose thready tissue 
referred to, took the case for one of placenta prtevia. Several 
obstetricians of eminence subsequently saw the patient ; and so 
closely did the mass presenting at the os resemble to the touch 
placenta, that the view above mentioned was admitted as a pos- 
sibility by each one of them. 

Dr. BopEB had had under his care the patient whose case had 
beon mentioned by Dr. Herman. Aged twenty-eight, she had been 
married six years, believed herself to be pregnant for the first 
tiuie, and had engaged a medical man of great expenence to 
attend ht'r in her expected confinement. Her history in all 
respects was like that of pregnancy, and her general health was 
good. At the seventh month she was seized with a severe 
flooding, then a slight oozing for a few days, succeeded by 
another flooding. The case was supposed to be one of placenta 
pnevia ; her medical attendant sent for Dr. Boper in the middle 
of the night. The abdomen, both iu shape and size, was like that 
of pregnancy at seven months. The os uteri admitted two fingers, 
and though it he could feel a mass like placenta. It was too 
rigid to allow of the passage of more than two fingers. The 
fcertal heart could not be heard, but there was a loud bruit in 
each iliac region, and along the linea alba, and towards the um- 
bilicus it assumed a musical tone. Labour did not come on. 
From time to time she had slight lloodings, but remained in 
good health. Fourteen mouths aft«r the date of supposed prog- 



186 



PREOHAHCT COMFLICATEI) BT 



oaucy Bbe was taken into the Bojal Hoapital, Waterloo £cad, 
where she w&s seen bj Dr. Barnes and Dr. John Williams. A 
portion of the mass was remoTed with potjpus forceps, but on 
microscopic examination no placental structure could be obserred. 
At this time the os uteri was of the same size as at first, and 
the mass could be felt. She subsequently came under Di. Her- 
man's care at the London Hospital, where she died rather snd- 
deolf of septicemia. On post-mortem examination the case was 
found to be oue of soft medullary cancer. This seemed to have 
commeaced outside the ut«rua, to hare invaded the uterine wall, 
and a portion projected into the uterine cavity. The uterus 
itself was about five or six inches in length, and its walls at the 
part not affected by the disease were much thickened. 

Dr. Heywood Suith did not consider that the intra-uterine 
growths described quite answered to the ordinary characteristica 
of fibroids — the irregularity and tendency to break down of their 
surface wna not like that of fibrous tumours ; and, having r^aid 
to Dr. Galabin's observation that they were liable to recur, he 
ventured to remark that he believed these growths presented a 
feature more resembling some morbid tissue, than as a malignant 
growth, for true fibroids, though fresh ones might be developed, 
did not recur. He would like to know on what grounds they 
were supposed to be fibroids at all. 

Dr. Fancookt Babses had distinctly heard the sound called 
placental souffle in Dr. Roper's case. He should like to hear 
some explanation of these sounds. 



I 
I 




A CASE OF PREGNANCY COMPLICATED BT CAN- 
CER OF THE CERVLS UTERI, FOLLOWED BT 
PYEMIA ASSOCIATED WITH SYMPTOMS 
SIMDLATING DIPHTHEBU. 

By AiTRxa L. Galabin, M.D. 

Ik November, 1878, I w»b called to see Susan C— 
34, in consultation with Dr. E. A. Wallace. She waa 
married at tho age of twonty-five, and was the mother of 
five children, the last of which wouJk^SfdlQ March 19th, 



I 



CANCZB OP THE CBBTIX CTEBl. 187 

1877. After this menBtrnation was regular up to March 
12th, 1878. After this she saw nothing up to the IDthof 
May. Ever since that time there liad been irregular 
metrorrhagia, with the exception of one month's clear 
interval from the middle of July to the middle of August. 
On October 3rd she lost a considerable quantity of blood 
while riding in a tram car. 

The patient was evidently pregnant, but on examination 
of the size of the utems, and the date of quickening, 
appeared to indicate tbat the pregnancy dated, not from 
the cessation o£ menses on March 12th, but from about 
the middle of May, the time at which metrorrhagia com- 
menced, and was of rather less than six months' duration. 
The whole circuit of the oa uteri appeared to bo involved 
in cancer, and was fixed. On the left side was a cleft 
reaching the vaginal reflection, and apparently passing to 
the outside limit of the cancerous growth in that situation. 
It gave the impression that it had existed anteriorly to 
the development of the cancer. The growth was hard, 
and bled slightly on touching, but not to any extent. I 
was so impressed by its firmness that, although in two 
former cases in which the whole circnit of the os appeared 
to be involved in cancer, 1 bad suocessfully delivered 
through the natural passages, I was disposed in this 
instance to entertain the idea of Cataarian section. Con- 
sidering that it was a case in which some regard might 
reasonably be paid to the life of the child, I recommended 
that we should wait till the child was viable, should then 
induce labour, and, if no spontaneous dilatation of the 
cervix occurred, should perform Cssarian section. 

The husband and friends, however, were very anxious 
that the child's life should ?iot be saved, one of the former 
children being an idiot. They and the patient, therefore, 
refased to permit Cfesarian section. 

A little later tbe patient went to conaolt Dr. Protheroe 
Smith. His opinion was that delivery should bo effected 
by the natural paesageit, but he considerod that tbe patient 
would run a very great risk. Eventually it was arranged 



188 rssasLScv comflicatId bt 

that the patient should come into Guy'e Hospital, a pro- 
mise being given that Ctesarian section should not be 
performed if delivery could be effected otherwise. She 
was admitted on December 17th, being then about seven 
months pregnant. 

On examination after her admission, the os uteri vaa 
found to be of a horseshoe shape, owing to the pro- 
jection into it of a mass growing anteriorly, and caasing 
eversion of the anterior lip of the cervix. The discharge 
had been offensive for the last fortnight only. 

Dr. Braxton Hicks examined the patient in consnlta- 
tion with me. He advised that labour should be induced, 
and that Barnes' bags should be used to dilate the 
cervix. 

On December 30th, the induction of labour wae com- 
menced, an elastic bongie being passed into the utems 
without rupturing the menibranes. Pains came on in i 
few hours, but little or no effect was produced upon the 
08. A vaginal injection of carbolic solution was used 
every four hours. 

On tho Slat, at 9 p.m., chloroform was administered, 
and the smallest Bamea' bag was introduced into the 
cervix. The membranes had provionsly ruptured. At 
12 p.m. pains were occnrring abont every four minutes. 
The temperature had risen to 101'4°, and pnlse to 100. 
Chloroform was again administered, and the Barnes' bag 
removed. Sufficient dilatation was found to have occurred 
to allow the introduction of the largest bag. At 9 a.m. on 
January lat, the temperature had fallen to 99'2, and the 
pulse below 100. On the removal of the Barnes' bag, 
but little further dilatation was found to have taken place, 
and what dilatation had occurred seemed to have been 
due chiefly to stretching of the base of the laceration 
already mentioned, which extended beyond the limits of 
the cancerous tissue on the left side. The os was still of 
a horse-shoe shape, and measured a Uttle more than two 
inches laterally, antero-posteriorly the margins were 
almost in contact, owing to the projection of the mass 



CANCEE OF TBE CEEVIS DTEBI. 



189 



t 
■ 



L 



growing from the antierior lip. I now decided to leave 
the case to nature for a time, in order to see whether any 
further dilatation of the os would take place spontaneously. 
By 2 p.m., however, no advance bad been made, although 
pains continued pretty vigorously. The pulse was about 
100, temp. 101-6°. 

Chloroform was then administered, and I first en- 
deavoured to turn. This proved to be impossible, the os 
being too small to admit the hand, and the rigid con- 
traction of the uterus being too great to allow of bipolar 
version. I succeeded, however, in applying long forceps, 
and made moderate traction, but the os did not yield in 
the slightest degree. The head was then perforated and 
crushed by the cepbalotribe, but the flattened mass did 
not readily enter the cervix, although rotated so as to 
bring its largest diameter into a transverse position, in 
accordance with the largest diameter of the cervix. The 
cepbalotribe was therefore taken off, and Barnes' cranio- 
tomy forceps applied. By eteady traction, the head 
became gradually elongated into a conical shape, and was 
delivered without the use of any great force. The body 
gave no trouble, and the placenta was expelled naturally. 
The whole of these proceedings, including the adminis- 
tration of the anaesthetic, were completed within an hour. 
At 5 p.m. pulse was 114, temp. 102*2°, bat by 9.30 p.m. 
pulse had fallen to 98, and temperature to 99°. Vaginal 
injections of carbolic solution were used every two hours. 

At 5 p.m. on the following day, January 2nd, tempera- 
ture had risen to 103*8°, pulae to 120, and a slight smell 
was noticed in the discharge. Quinine was given in five- 
grain doses every four hours. On the 3rd the pulse had 
fallen to 100, and temperature to 97", and the patient 
appeared to he doing fairly well. From the 3rd to the 
10th, temperature and pulso were very variable, the tempe- 
rature ranging from 98*4° up to 103*8°, reached on one 
evening. On the lith iu&ammation of the tonsils and 
fauces was noticed, and a gargle of chlorate of potash was 
ordered for it. On the 7th she complained of pain in the 



190 



FBS&KAHCT COHPUOATBD BT 



chest, but nothing was detected on 



left aide of 

auscnltation. 

On the jooming of the 10th she had rigors, in which 
the pulse rose to 140, and the temperature to 103'4''. 
The inflammation of the throat was found to be Increaaed, 
and a pleuritic rub waa detected on the left aide. Per- 
chloride of iron with chlorate of potash was ordered every 
three hours. 

Oil the 11th she appeared to be better, and the pulse 
had fallen to 86, temperature to OS'i". A depoait of 
membrane, however, was now noticed on the tonsils, and, 
still more, on the posterior wall of the pharynx. The 
urine, which up to this time had been normal, waa now 
found to contain a small quantity of albumen, and this 
was confirmed from a specimen withdrawn by catheter. I 
therefore asked my colleague. Dr. Frederick Taylor, to 
see the patient, with reference to the diagnosis of the 
affection of the throat. He reported that, from the fact 
of the membrane affecting chiefly the pharynx, and not 
simply the tonsils, and from the coincidence of albu- 
minuria, he considered that the affection of the throat waa 
almost certainly diphtheria, and recommended the removal 
of the patient to a separate ward. This waa accordingly 
carried out. In the evening there was evidence of 
extension of the pleurisy, and there were moist rales all 
over the back of the chest. The amount of membrane on 
the throat increased for some days, and then diminished 
gradually. On the 1-lth the pain in the throat waa much 
relieved, and the albumen in the urine was reduced to a 
slight trace. On the IGth it had disappeared. The 
patient, however, had a rigor again on this day, continued 
to get worse, and died on the 18th, seventeen days after 
delivery. Qniniue in tea-grain doses had been given 
from the 13th. 

The following account of the autopsy is taken from the 
report of my colleague. Dr. Goodhart, who made the 
examination : 

" Lwngs. — The lower lobe of the right lung was 



I 



CAKOBR or THE CEBTIX UTKBI, 191 

cedemcitoDB, and in its Bnbstance were four or five small 
absceaaes, which were in all cases connected with plugs 

the terminal pulmonary arteries. In the left lung 
there was a largo ragged cavity at the basej due to a 
sloughing pneumonia, and in addition there were three 
or four surface infarcts in the lower lobe. 

' JJter\iS. — The oa and cervix were occupied by a 
yellowish ulcer. The edge of the os was everted and a 
little thickened. The floor, when sectioned, was seen to 
be composed of a yellowish infiltrating growth. In the 
middle of the anterior lip was an amygdaloid process 
running from the os internum to externum, somewhat 
discolored and looking more like swollen mucous mem- 
brane than any new growth. On section, it was found to 
be a hypertrophied muscular coat, looking like a fibro- 

• myoma covered over with tho mucous membrane of the 
cervix, and in its centre was a small collection of pus, 
apparently in a dilated vein. Jlxtemal to the cervix on 
the right side there was a plexus of dilated veins, which 
were full of pus, and from them this extended into the 
vena cava. At the latter part there was a cylinder of 
firm organised clot lining the vein wall, and a centrd 
greenish soft material, like bad pus. In the right ovary 
was a hard yellowish mass, which no one would have 
suspected to be a true corpus luteum, but there was 
nothing else on either aide to answer to it. 

" The uterus was large, soft, and fatty looking. The 
internal snrface ecchymosed and covered with a little 
g rnm on s- looking stnff. No pus in any of the sinuses of 
the body, nor in the plexus of veins by its side, nor in 
the broad ligament. The placental site was marked by 
a shilling- si zed, button-shaped excrescence, with a corru- 
gated surface, on the anterior snrface of the fundus near 
I the orifice of the right Fallopian tube. 
" Throat, pkaryine, fc. — From the tonsils, backward 
over the posterior wall of the pharynx, there was a thin 
adherent layer of membrane. The tonsils themselves 
were not so mnoh involved, although said to be so daring 



192 PEEOJJANCT COMPLICATED Bt 

life. The membrane was only slightly adherent 
peeled o£E without leaving any roughness of surface or 
ecchymosis behind, bo that I am inclined to think that it 
is merely a ' thrush,' due to the dying state the patient bad 
lain in for some days. Under the microscope, the mem- 
brane consisted of mycelinm fnngns, and the myceliam 
spores were in large qnantity. No catarrhal prodnots 
whatever. This, I think, confirms its non-diphtberitio 
nature. 

"Kidneys. — Weighed 10 oz. Very pale. The capsule 
strips off very badly. A little stellate congestion. They 
are not good organs, bnt there is none of the acute con- 
gestion one would have expected in diphtheritic albu- 
minuria. Therefore, I think these organs rather militated 
against the view of diphtheria." 

Although the question of the treatment o£ pregnancy 
complicated by cancer of the cervix has already been 
discussed by the Society, I thought that this case i 
bo of interest, more especially as regards the relation to 
eepticsemia or pyiemia of the pseudo-diphtheritic or 
diphtheritic affection of the throat. I am not quite able 
to agree with Dr. Goodhart that it was simply a " thrush " 
due to the dying state of the patient. For, first, no 
other part of the mouth was affected ; secondly, the 
affection of the throat was a very painful one, and was 
one of the earliest unfavorable symptoms noticed, com- 
mencing five clays after delivery, and twelve days before 
death; thirdly, the membrane was first noticed when the 
pulse was only 8(5 and temperature 98'4°; and, fourthly, 
the albuminuria commenced with the appearance of 
membrane, and disappeared as the membrane diminished. 

Three possible views might apparently be taken : — (1) 
That the membrane was simply a thrush, as held by Dr. 
Goodhart ; (2) that there was true diphtheria complicating 
pysemiaj (3) the view that I was inclined myself to 
adopt, both during the patient's life and after her death, 
that the membrane was of a pseudo-diphtheritic character, 
the result of the septicaemia or pytemia, and was thus 






CANCER OF THE CERVIX UTEItl. 193 

comparable with the apparently diphtheritic deposits in 
vagina and throat, which have been observed in some 
forms of virulent puerperal septiciemiftj espocially when 
epidemic in lying-in institutions. Since both sopticEemia 
and diphtheria are attributed to micrococci in the present 
day, it would eeem qnite possible that the membrane may 
have been due to micrococci in the first instance, and that 
the coarser myceliam fungus simply found in it a snitable 
nidus for growth. The question may also arise whether 
there may be an affection approximating to diphtheria 
without actually constituting that disease, or whether the 
organisms of diphtheria may be developed out of those 
which have initially a different nature. 

It would hardly seem in accordance with modem views 
to hold that the mycelium fungus infected the general 
system, and led to the albuminuria and other symptoms, 
especially as there was an obvious local cause for the 
pysemia. 

Microscopic sections are now shown — (1) of the mucous 
membrane of the pharynx, with the membranous exudation 
tn situ ; (2) of the kidney ; (3) of the cancerous growth 
in the cervix. 

The membrane on the pharynx is shown to consist of 
detached epithelial cells, mingled with a considerable 
number of leucocytes and granular matter, and the myce- 
lium and spores of fungus. A considerable portion of the 
thickness of the squamous epithelium is thrown oS, and, 
at several points, scarcely any remains, while there is an 
effusion of leucocytes ,in the cellular tissue beneath. 
Both the destruction Of epithelium, however, and the 
effusion of leucocytes are less than is usually seen in true 
diphtheria. The mycelium penetrates the epithelium in 
situ as far as its deeper surface. 

The kidney appears to me to show more of an acute 
change than Dr. Goodhart inferred to exist from its naked- 
eye appearance. I am unable to detect any chronic 
cirrhotic change. The epithelium, however, is proliferating, 
filling up the tubes irregularly, so that the lumen is gene- 
VOL. XIII I. 13 



194 



PREOKAHCT COMPLICATED BY CANCER. 



rally contracted and etellate instead of round. Some of 
the tubes appear to be more or less filled with small 
nuclear cells instead of with the usual epithelium. 

The growth in the cervix show a characters intermediate 
between epithelioma and carcinoma, but approximating 
most Dearly to the latter. It would correspond, therefore, 
with what I beliovo to be the general course of cancer of 
the cervix, namely, a commencement in the form of epi- 
thelioma, which more or less rapidly merges into carci- 
noma. The cells are in parts arranged in alveoli. They 
are, however, cemented together like the cells of squamous 
epithelium, and in some parts there are extensive cell- 
mnaaea, in the midst o£ the stroma, without aoy outlying 
cluaterB. At other parts, on the border of the growth, 
groups of less than a dozen cemented epithelial cells are 
seen ro the midst of the apparently normal tissue. No 
border of " palisade cells " to the cell-masses is anywhere 
seen, nor any epithelial globes. The cell-masses have all 
a yellowish tint. 

The amount of cancerous tissue found at the post- 
mortem examination was less than had existed at the time 
of delivery, the projecting mass from the anterior tip of 
the cervix having sloughed away, 

No unsanitary condition was known to exist in the 
ward at the time when this patient was in it, nor was any 
other patient unfavorably affected. 



L 



Dr. Hbeman expressed his opinion that the therapeutic means 
in these c&ses which offered the greatest hope of benefit to the 
mother were (I) the induction of abortion at the earliest possible 
period, and (2) the removal of as much of the diseased tissue as 
could be safely cut or burnt away. 

Dr. EoPEE remarked that when a patient in the seventh or 
eighth month of pregoancj with cancer of the cervix first comes 
under notice at this period, only one of two modes of deliveiy 
could be selected — (1) Dehvery per viae TUiturak* after induction 
of premature labour ; (2) Ctesarcan section. But he wished to , 
put these questions : If a patient with malignant disease of the 
cerAix came under notice when only three mouths advanced in j 
pregnancy, should pregnancy be allowed to go on till the child 



I 
I 



DISSECTION OP A MALFORMED CHILD. 195 

became viable ? Or should abortion be produced at once? He 
hikd, at the present time, a patient under his care, three months 
advanced in pregnancy, with Duilignant disease of the entire 
Bubatance of the cervix. Looking to the prospect of the case in 
four or five months hence, he believed that the production of 
abortion was the proper treatment. 

Dr. Godson mentioned a case which occuired at the City of 
London Lying-in Hospital during a severe endemic of puerperal 
fever, in which the symptoms were almost identical with those of 
Dr. Qalabin's patient. She was almost the only woman who 
recovered, wfaich tended strongly to prove that the disease was 
septic, and not the thrush of a moribuod woman spoken of by 
Dr. (Joodhart. 

Dr. Edib thought the question of whether the whole circum- 
ference of the cervix was involved In the malignant degeneration 
a verv important one. In those coses where even a quarter of it 
remamed healthy, dilatation could be effected either naturally or 
artificially, so as to allow the transit of the fcetus ; but if the 
whole circumference wore involved, even though it was not to a 
considerable extent, dilatation would not take place. He had 
brought before the Society a case some years since, where 
delivery was accomplished by the aid of the forceps, the child 
being bom alive and still living. Id this case about two thirds 
only of the cervix was involved, the healthy portion alone dilating. 
The mother went ou well for the first week, but ultimately suc- 
cumbed with woU-marked symptoms of pytemia, owing doubtless 
to the bruising of the tissuesduringdelivery. Where the whole 
circumference of the cervix was involved the bett«r plan would 
probably be to perform CceBarian section, supposing that the 
condition had not been detected until labour had set in at the 
normal period. 



KOTES ON THE DISSECTION OP A MAL- 
FORMED CHILD. 

By W. Lenton Hbath, M.B. Lond., F.R.C.S. 

The child to which those notes refer, and of which I 
show yon tho dissection to-night, was exhibited at the 
November meeting of this Society when it was about a 
fortnight old. At that time it was slightly hydrocephalic, 
and, in addition, showed great changes in the development 



196 DlSSBCTtON OP A KALPOBHED CHILD. 

u{ both its arms, simulating in appearance some of the 
easoEi described us being due to iutra-nterine amputationft, 
whilst tlie lower limbs also showed groat changes from 
the natural condition, for there appeared to be an almost 
complete absence of both femora, and the feet — which were 
in a position, one of extreme talipes eqaino-varnsj the 
other, in that of extreme T-algus — only had four digits in 
each. 

The subeequent hietory of the child was briefly the 
following. Slowly bnt progressively from its birth the 
head became larger, until at the time of its death it 
measured twenty-two inches in circumference, the sagittal 
suture was seven eighths of an inch broad, and the coronal 
half an inch. All the fontanellea were greatly enlarged, the 
ohtique measurement of the anterior being nearly an inch 
and three quarters. 

For the first two or three weeks the child took milk 
well from a bottle and kept up its nutrition, causing no 
little alarm to its grandmother, who feared it might live; 
but about this time it began to fail, refused its food, and 
lost flesh, slowly at first, but thou more rapidly until ita 
death, which resulted from inanition at the end of sii 
weeks. 

During the last fortnight it bad frequent oonTulsive 
attacks, lasting only a few seconds, in which the child 
became rigid and its face of a livid colour. These attacks, 
which occurred at one time as often as six or eight times 
in a day, ceased altogether for the last forty-eight hours of 
its life. 

Dissection. — At the time of death the head presented 
the ordinary appearances of hydrocephalus, but it very ' 
soon became flaccid, bo that when it was opened the 
greater part of the brain had become dtffiueiit, being, I 
suppose, rendered softer and liable to more rapid decom- 
position by absorbing water from the fluid by which it was 
distended. All that could be seen was a thin layer of 
breaking down brain substance covered with its membranes 
and distended with Suid. 



DISSECTION OP * »a.LFOEUED CHILD. 



197 



I 
I 



The tisBues of the Bcalp did not appear altered, but the 
membrane corniectiDg the bones waa thin and translucent. 
The bones themselves seemed more flexible and thinner 
than natural. In parts the osseous matter was entirely 
absent in each of the frontal bones, and these apertures, 
which looked like windows, were closed by a thin trans- 
parent membrane. The largest of these apertures was in 
the left frontal bone, at its lower and outer angle, which 
was three quarters of an inch long and a third of an inch 
across. Two or three of these occurred in each frontal, 
but none in the parietal bones. 

The main vessels and nerves of the head and neck were 
normal, as also were the muscles. 

Tke contenfji of the thorax. — Heart with its great vesaela, 
lungs, and thymus gland were normal. 

Also the viscera of the abdomvn were natural, both as to 
position and shape, with the exception of the spleen, the 
lower end of which was continaed forward like a tail, 
GO that the whole organ looked very much like a leech 
curled up. 

The main vessels and their branches had the usual 
origins and distribution. 

The hypogastric arteries were obliterated beyond the 
top of the bladder ; the portions between this point and 
the internal iliacs were very large and thick, but the 
small in comparison with the thickness of the 
Teasel. The external circumflex arteries of the profunda 
(femoris) were given oft from the external iliacs jnat above 
Puu part's ligament. 

The muscles between the trunk and scapula, claviclo 
and hamorua, were c|uite natural, as were also the bones 
constituting the shoulder-girdle. 

Vpper extremities. — The right opper extremity was an 
inch and a half long, the whole of which length was taken 
up by the humerus, which was perfectly shaped at its 
upper part, but at its lower end, towards which it tapered 
slightly, there was a small oaseoua nodule on its inner 
Bide. This, appurently, was not an inner condyle, as the 



19 



DISSECTION OP A MALTOEMKD CHILD. 



humerus had not come to its natural ending, and there was 
no corresponding tubercle on its outer side. 

This end of the bone was covered with a small pad 
composed of fat and connective tissue, in which the brachial 
artery and median and ulnar nerves terminated. The 
whole was covered with skin, which presented a projection, 
but which, by no stretch of imagination, could be likened 
to a rudimentary forearm or other normal part. The 
pectoralia major and deltoid muscles had normal origina 
and insertions, bnt at their contiguous margins were inti- 
mately united as one muscle. 

The coraco-brachialis {which had the usual origin) was 
joined below by a narrow continuous strip of muscle, con- 
stituting the short bead of the biceps and brachialis anticns, 
which was attached to the front surface of the humerua 
and the anterior surface of the tubercle on the inner side 
of the lower end. There was no long head of the biceps. 
The triceps was represented by a thin layer of muscle 
attached to the posterior aspect of the shaft, and which 
was joined above with the deltoid, and lower down by the 
teres major and latissimue dorsi muscles. The regular 
vessels and nerves of this limb, as far as could be made 
oat, were all representative, and, allowing for the general 
alterations of the mnscles, were naturally distributed. 

The left upper extremity was two and a half inches in 
length and presented at its lower end a palm-like pad of 
skin, in which vessels and nerves ended by dividing into 
small branches and plexuses, but here also no trace of a hand 
could be made out. The humerus in this arm was what 
might be considered of natural length, but prolonged from 
its lower and outer end ; where its external condyle should 
have been was a shaft-like projection of bone, about half 
an inch long, continued in the direction of the radius. 
There was no joint between this and the humerus, of which 
it was a direct continuation. It was on this projection 
that the pad of skin above mentioned was placed. The 
anterior surface of this projection gave insertion to a 
well-developed biceps and the posterior to the triceps, bo 



'ORMED CHILD. 



191 



that it can bardly be looked upon aB either a homologue 
of tbe radius or ulna alone. 

At the inner aide of the lower end of the humerus was 
a bony projection which may possibly be regarded as an 
internal condyle; and just behind this, separated from it 
by a slight furrow, was another similar projection. After 
buying examined carefully this lower end of tbe bone I 
was led to regard these projections not as condyles, bat 
as something altogether anomalous in tbe development of 
this part. The muscular attachment to the upper and 
anterior parts of the shaft of the bone were natural, but 
there was an absence below of the origins of the supinator 
radii longus and extensor carpi radiolis longior muscles 
and all those that should be attached to the inner and 
outer condyles. 

Tbe biceps and triceps muscles were natural as to size 
and origins, and it was only at their lower extromitieB, 
where they were attached to the projecting shaft of bone, 
that any abnormality was found. The brachial artery 
gave off its usual branches in the upper arm, and there 
were present the median, ulnar, musculo-cutaneous, mus- 
oulo-spinal, and the cutaneous nerves, all of which had the 
usual relations in this part of the arm. 

Lower extremilws. — The pelvis was of the natural shape, 
but the acetabula were absent on both sides, and where 
they should have been — that is, at the junction of the sepa- 
rate iliac, ischial, and pubic bones — there was a heaping 
up instead of a socket. The bones were all separated here 
and moved freely on one another, a synovial membrane 
lining their contiguous surfaces. On part of the promon- 
tory produced by the junction of these bones, namely, on 
that part formed by the ischium, there was a smooth, 
somewhat convex surface, about the size of a pea, and this 
part articulated with the upper end of the stump of femur. 
On the dorsum of the ilium, just below the anterior 
inferior spine, was a smooth surface as big as a split pea, 
and enomsted with cartilage, and with which the great 
trochanter, which was completely detached from tbe femur, 



I 



DISSECTION OP A MALPOKMED CHILD. 201 

The right tibia was also curYed forwards and inwards, 
and the shaft of the fibula, as in the opposite limb, was 
only a cartilaginous cord, but its lower end, constituting 
the outer malleolus, was ossified. 

The muscles of this leg were also regular with the 
exception of there being only one peroneus, which on this 
side, although combining both longus and brevis at its 
origin, was inserted as peroneus brevis. 

The foot was in a state of equino varus, and also had 
only four toes, the little toe on this side being absent. 
The vessels and nerves of this leg were found in their 
natural places. 

Eemarks. — From the general characters which this child 
presented I think we can only look upon it, not as one 
showing arrested but altogether abnormal development, 
for, whichever of its deformities we may take, we cannot 
explain it by imagining that development has gone on 
rightly to a certain point and then has become suddenly, 
but simply, arrested, but rather that natural processes 
have become greatly perverted. 

Dr. BoPEB considered the dissection of this fcetus as of great 
interest and iin|K>rttLUce in reference to the (juestion of so-called 
intra- ut«riueamputatioD. This he believed to be an exceedingly 
rare phenomenon, moat of Buch alleged cases being the result of 
arrest of develojiment and not of amputation. External exami- 
nation could in many <:aiiea determine them to be cases of arrest 
of development. In some canes, however, the question could not 
be decided without dissection. 

Dr. Babnes reminded Dr. Boper that there was a case, appa- 
rently welt authenticated, of a child exhibiting a healed stump 
and the amputated foot being found together in ufiro. 

Mr. FowDUELi. wished to say he had listened with much plea 
sure and interest to the valuable paper just read. Some two or 
three months back he dehvered a [mtient of a female child at 
full term with a deformity of this nature ; development had 
ceased at the lower end of the right humerus, where the arm 
terminated in two small fleshy nodules, an api>arent effort to 
form fingers ; the forearm and hand were entirely absent. There 
was {if he might use the term) a sort of " compensatory develop- 
ment " in the left hand, where two thumbs joined together 
throughout were to be seen. lo every other resi>ect the child 



202 



DIBSECTION ( 



. MALFORMED CHILD. 



was a fine and bealtbj ooe, showing no signs whatever of abnor- 
mal brain development. He hoped to get the sanction of the 
parents to bring the child before the Society, and should be do 
BO he would bring her at a future meeting. 

Dr. Hbrman asked whether diiring life,' or npon diaaection, 
the condition of the hip-jointa in this case in an; waj resembled 
that which occasioned the so-called " congenital distocatioa " of 
the hip P 

In reply, Dr. Heath said that during life the case did 
present some of the characters of congenital dislocation of the 
nip-joint, but from the exteat of the deformity and the mal- 
development of other bones it was thought that something more 
than simple congenital dislocation existed, and this conclusion 
was borne out by the condition of the parts described in the 
dissection, to which Dr. Herman was referred. 



OCTOBER 5th, 1881. 



J, MiTTHEwa Duncan, M.D., F.B,S. Ed., President, io tho 
Chair. 

Present — 30 Fellows and G viaitora, 

Books were presented by Mr. H. W. Cole, Dr. A. Courty, 
Mr. De Cristoforis, Dr. Edis, Dr. Festner, Dra. Hef^Rr (ind 
Kaltenbach, Dr. Mivcari, Dr. R. J. Nunn, Dr. Playfair, 
Dr. Wasaeige, Univeraity CoUogo and Itospitiil, and tho 
American Gyn (ecological Society. 

George Town Penny, M.R.C.S., was admitted a Fdlow 
of the Society, and Goorgo Worthingtoii, M.R.G.S. 
(Sidcup), was declared admitted. 

Herbert George Cronk, M.B. Cantab., John Mill Frod- 
aham, M.D. Ed., and Charles Suthward do Lacy Lai^y, 
M.B. Oxon., were elected Fellows. 

The following gentlemen were propoaod for election : 
William Alex. Uepbarn, F.F.P.S.G. (Coxhoe), Arthur 

Perigal, M.D. {New Barnet), Archibald Sloun, M.B. 

(Glasgow), and Francis Perloy Taylor, P.R.C.S. Ed. 

(Charlotte Town, Prince Edward lalaud). 



&%^ or AeA dna^ pcgaaa^. 



P. 



BUGHTED A3.T) ATEOPHIED EMBBTO. 



Dk. Hkuus eslubit^d a spe^men cotiEistiiig of an oval 
isCj me&snriDg li of an inch Icag by { of an inch trans- 
Tenelj, iritb tlun, translocent irall, apparestl; (Xmlamm^ 
clew fluid. lu vail wae Dot qaite smooth, being thicker 
»t some parts than others, and baTtng bags of deli<»te 
roembrame atta>ched to both its inner and outer surfaces; 
bat there was nothing like chorionic villL Wilhin it, 
attached to its wall, was a solid body about as big as a 
large pin's head ; and at one end of the sac was an air 
bubble. This specimen had been given to him by Mr. 
Bimpson, of Fore Street, by whom be bad been informed 
that it had been discharged after eymptoms resembling 
those of miscarriage from a woman who supposed herself 
three and a half months pregnant, and followed after 
some hoars by a placenta with a rudimentary cord. No 
fcctns had been noticed. Dr. Herman was inclined to 
regard the specimen as the dropsical membranes of a 
blighted and atrophied embryo. 

an also exhibited an acardiac foetus. 



POLYPI UTERI. 



De. Edis exhibited two polypi uteri. The smaller one, 
about the size o£ a walnut, he had removed from a patient 
set. 46, mother of seven children, who had suffered from 
severe periodical uterine haemorrhages for over a twelve- 
month. About two months before the date of operation she 
felt something come down in the vagina, where it remained 
for about a fortnight and then receded at the time ofher 
next period, which was very profuse. 

On examination the uterus was found to be bulky, 
retroverted, the os uteri slightly patulous, barely admitting 
the tip of the finger, which detected a round, smooth pro- 
jection occupying the cavity of the uterus, A small pair 
of ovum forceps was passed within the cervix, the polypus 
seized, and torsion employed until the tumour was 
detached, when it was removed without much difficulty. 
Scarcely an ounce of blood was lost. 

The second polypus was a 6rm, fibroid growth, that had 
probably been at one time intramural, and become 
gradually extruded from tho uterus. It was abont tho 
size of a goose's egg, and was attached to the posterior 
wall of the ntems, hanging out in the vagina. The 
patient was %t. 40, married and sterile. She was per- 
fectly well until six weeks before being seen, when some- 
thing came down in the passage. A month subsequenlly 
she had severe flooding, and lost a considerable quantity. 
Dr. Edis removed it by means of the single wire ecraseur. 
The growth was removed from the vagina with some little 
difficulty by the aid of ovum forceps. No hiemorrhago 
occurred either at the time of operation or sabsequently. 



CYSTS FKOM THE LABIA MINORA. 

De. WlLTSHlEB exhibited two cysts from the labia 
minora. They were removed from different patients, and 
contained tronslocent fluid. They were, he believed, 
extremely rare, for, with the exception of one other case, 
he had never seen another, and the only mention made of 
them in any work on women's diseases with which he 
was acquainted was the following by Schroeder, in von 
'Ziemasen's Cyclopiedia.' 

" Other cysts, however, occur npon both the labia 
majora and the labia minora; they remain for the most 
part small, though exceptionally they may grow to be as 
large as a child's head. Their etiology ia obscure. It ii 
possible that they develop in consequence of contuaione of 
the connective tissue, and probably also in connection 
with haemorrhages. The cyst wall is hrm and distinct, 
and the contents may be cither serous or mucous in 
character and have a variable colour." 

They were attached in a slightly pendulous manner to 
tho apex of the labia majora, and, as would be seen, w 
respectively of the size of a small walnut and a hazel nut. 
Such growths were preferably removed by the clamp and 
cautery. The specimens were interesting chiefly on 
account of their" rarity. 

Dr. Matthbws Duhcan mentioned that a, similitr specimen 
was to be fouud in the Muiieum of St. Bartholomew's Hospital. 



FCETAL HEAD. 



Dr. Brcnton showed plaster casts of a fecial head, 
which he had delivered for a neighbouring practitioner. 



DISCHABQE OS UEUBKANS IN CEBTICAL EKDOMETfilTlS. 207 

after forceps above the pelvic brim had been tried in 
vaiD, then version performed: — The inlet was found so 
narrow as not to permit passage of the head even lu this 
way. After also trying to extract the head without 
BuccesB he applied his modification of Assalini's forceps, 
then failing with them, retained them upon the head, 
ampntated the body to gain room, and having perforated 
between the blades of the forcepB, extracted the after 
coming head. 

Dr. Ems thought th&t under the circumstaniXB Br. Brunton 
was quite justified in removing the body of tho child in order 
to facilitate the operation of pterforation. We met occaBionally 
with cascB where the pelria waa bo small that it was almost 
impossible to perform any manipulation above the brim so long 
as the body of tho fcetus occupied the vaginal passage, more 
especially as the head was securely filed between the blades of 
the forceps. The risk of injuring the perineum was alao much 
lessened. 

Dr. WiLTSHiEE thought it undesimble that ]»rfora,tion should 
be practised through the denser TOftion of the temporal bone 
where a softer spot could be selected j but doubtless in the 
present case bo excellent an operator aa Dr. Brunton concluded 
that there was no option. 



PERIODICAL DISCHARGE OP MEMBRANE IN 
CERVICAL ENDOMETRITIS. 

Dr. Galabin showed microBcopic sections of u membrane 
passed by a tcarricd woman let. 35. She was sterile, and 
suffered from aevero intermittent pain during the menstrual 
flow, at which time she passed some small clots or solid 
fragments. Halt way between the menstrual periods she 
had an attack of similar pains, ending in the discharge of 
a more definite pieco of membrane, from one of which the 
seciion shown was taken. It resembled at first sight 
embryonic tissue, having round as well as angular or 
elongated cells, with fibrillie among them. Tho border 



208 DtaCHA^KQB or UEHBRANS IN CERVICAL EUDOUBTRtTlS. 

was fringed with cylindrical epithelinm, resembling that 
of tho cervical canal. On careful examination it was 
seen tbat this epithelium was upside-down, the narrower 
or originally attached extremities of the cells now forming 
the free surface. It was clear, therefore, that the mem- 
brano was an exudation on the surface of the cervical 
canal of sufficient tenacity to bring away with it the 
epithelium on detachment. 

The fibrillBe among the cells were formed by fibrin, and 
tho angular or elongated character of many of the cells 
showed that there was some attempt at organisation. 
Tho outline of the epithelial border showed that it came 
from the villous prominences of the cervical canal. The 
case must be regarded as one of membranous or exfoliative 
cervical endometritis. He coald not account for the 
periodical discharge of the membrane, but presumed that 
it might be formed under the influence of the menstrual 
niaus, but not become det-ached till the middle of the 
intermenstrual interval. After treatment by local appli- 
cations to the cervical canal the discharge of membrane 
ceased. 



Dr. WiLTSHiBK thought the fortnightly exacerbation explicable 
on the hjtiotheais of hebdomadal periodicity which piervaded the 
menatnial function. He knew of many eases of fortnightly 
menorrhagia. Did tho specimen throw any light on the hegin- 
ningH of epithelial cancer ? If the pathological proceaa resembled 
that so ably shown by Mr. ButHu in cancer of the breast fol- 
lowing eczema of the nipple, it had most important bearings upon 
ti-eatment. 



ON THE RELATION OF ANTEFLEXION OF THE 
UTERUS TO DYSMENOREHCEA. 



7 G. Eenest Hekman, M.B. Loud., M.R.C.P. Loud., 
F.R.C.S. Eng. 



In patients who suffer from painful menstruation, ante- 
flexion of the uterus is often found. This fact has been 
familiar to the profession for half a century, and the in- 
terpretation has been put upon it, that the anteflexion causes 
the dyameuorrhcDa. This interpretation has been accepted 
and acted upon by many g-ynsecologista of the greatest 
reputation, and denied by others of equal eminence. An 
inquiry into the nature of the counection between painful 
menstruation and bending forwards of the uterus is there- 
fcire not uncalled for. 

The mode in which flexion of the uterus is commonly 
supposed to cause dysmenorrbtBa is the following : — It is 
said that at the point of flesion the uterine canal is bent 
at au angle, and its wall on the concave aide of the bend 
projects inwards, forming a spur or promontory, which 
blocks up the passage and prevents the menstrual fluid 
from getting out. The retained secretion distends the 
uterine cavity, and provokes painful contractions of the 
Dteriue muscular fibre. Sometimes the uterus cannot 
force the pent-np blood past the barrier formed by the 
flexion, and it may then be driven along the Fallopian 
tubes, forming a pelvic biematocele. 

The object of the present paper is to inquire whether 
this is supported by facts so far as anteflexion is con- 
cerned. 

In examining this theory we have to ask (1) what 
kind of evidence U required to prove it ? (-} what 
amount of such evidence have we P 

VOL. tsiii. 14 



210 OK THB BELATIOH 07 AKTEFLGXION OF 

The evidence required is of two kinda, anatomical and 
clinical. It will be best to begin with the anatomical, ae 
being the most simple and definite. 

First, it has to be Bhown, that in anteflexion of the 
uterus the canal ia bent at an angle, and that a spur of 
tissue projects inwards and blocks up the canal. Nearly 
all the works which adopt this theory contain diagrams 
which hare been copied from book to book, and which 
show this angulation and occlusion of the canal. Bat 
they are diagrams only, not professing to be drawn from 
nature, aud representing only the designer's idea of the 
shape of the nterus. When we look to actual specimens, 
or to drawings from nature, we seek in vain for these 
appearances. 

There are in London several specimens of acnte ante- 
flexion of the utems. There is one in University College 
Museum,* one in the Museum of the Royal College of 
Surgeons.t one in that of Guy's Hospital,J and another 
in that of the London Hospital.^ Le Gendre's at]as|| con- 
tains a drawing^ from nature of a section of the pelvis in 
which the nterna is seen to be acutely anteflexed. In 
each of these specimens, and in the plate, the curve of 
the uterine canal is quite gradual ; there is no angle, nor 
any projecting spur of tissue, nor is there any stenosis of 
the canal, nor dilatation of the uterine cavity. 

Next, if a specimen could be shown of retention of the 
menstrual blood and dilatation of the uterine cavity, for 
which no other cause than an anteflexion existed ; or if a 
pelvic ha;matocele, dependent upon etenosis of the uterine 
canal from anteflexion could be shown, the mechanical 
theory of the connection between anteflexion and dys- 
menorrhtca might be considered proved. The result of 

• t;. 

t 2663 E. 
I Z2B3». 



1 'Anntomie ChirnrfpcalB liomolographique,' Piiris, 1858. 



THE OTEEDS TO DYSMENOKBHfEA, 211 

my soarch for any such cases has been entirely negative. 
The literature of the subject is so voluminous, that I dare 
not say I have read everything that has been written upon 
it, but I have read carefully the principal works in which 
this theory is adopted. I have sought out every reference 
that I could get at, and I think I may say this, that if 
any piece of important evidence exists which I have not 
noticed, it has beon also overlooked by nearly all the chief 
writers on the subject. The only case that I can find 
which, although I venture to think it not important, yet 
might be referred to as bearing on the question, is one 
of hfematocele and anteflexion, given by Picard.* He 
adopts the mechanical theory, and believes that the eSuslon 
of blood arose from obstruction to the exit of the cata- 
menial flow. But the only reason he gives for thinking 
so 18, that " inflammatory symptoms " preceded the bsema- 
tocele; and ho asks, would this have occurred with a 
normal uterus 1 I do not think this case is important 
becanse there are many other causes that may produce 
pelvic htematocele and "inflammatory symptoms;" and 
there is in this case no evidence to show whether the 
reporter's view was correct or not. There are two oasoa of 
anteflexion with autopsies reported by Martin. f In one 
there was dysmcnorrhosa, and the uterine canal is said to 
have been very narrow; but there is no mention of any 
dilatation of the uterine cavity in either of thorn. 

Of course it does not follow that the theory is wrong 
because anatomical evidence of its correctness has not 
been produced. But if evidence of other kinds be 
equally wanting, then this deficiency becomes impor- 
tant. 

I would therefore here make the assertion, which can 
be refuted by the production of a single case, that there 
M no anatomical evidmtce that antefieieion of the uteru» 
causes any hindrance to the etcajie of Uie menstrual 
fluid. 

• • De« iDfleiioni do I'Otenu." p. 108. 

f 'Neiglmgen and Btfngiingen,' 2t« Aullige, S. St. 



212 



ON TBI KELATIOK OF ASTEPLEIIOK OP 



It may be urged, however, with reason, that this ab- 
sence of anatomical proof does not show the theory to be 
unaonnd, because evidence of this kind is diflScult to get. 
DysmenorrhtEa is seldom, if over, fatal; if fatal at all, it 
would only be after so many eecondary changes, inflam- 
matory and other, had taken place, that it would be 
impossible to isolate those directly and originally depen- 
dent on the flexion. Diseases of other parts of the body 
which cause death, very commonly themselves produce 
changes in the genital organs and alterations in the 
menstrual functions, so that inferences cannot safely be 
drawn from -them. When death results from accident, it 
is seldom that we have the opportunity of previously 
making full inquiry into the condition of menstruation. 
The nature of an obstetrician's duties prevents him, as a 
rule, from frequently making post-mortem examinationa; 
and therefore it generally happens that in large hospitals 
these are made by a member of the staff who has no par- 
ticular interest in, or knowledge of, gynaecology. These 
are all reasons why wc might expect anatomical proof to 
be furnished but slowly. 

On the other hand, it is now more than fifty years 
since the doctrine of the importance of uterine flexiona 
was promulgated; during that time numbers of gynsBCo- 
logists have directed their attention to the subject, and 
the medical press of all countries has teemed with 
papers upon it ; it is therefore very surprising, seeing 
how common a condition anteflexion is, that if it really 
produce such changes, no one should during all that time 
have met with, or thought it worth while to put on 
record, a case illustrating them. 

We pass now to the more important, because more 
easily obtained, clmicat evidence. The arguments drawn 
from clinical phenomena which have been brought for- 
ward in support or illustration of this theory, fall into 
four groups. I. That drawn from the patient's descrip- 
tion of her pain. 2. That from difiiculty in introducing 
the sound. 3. That from the frequency with which dys- 



THE OTEHDS TO DTSMENORR#(KA. 



213 



menorrlicea and anteflexion are associated. 4. That from 
the effect of treatment. 

I. It is said tbat women suffering from flosioii of the 
ateras describe pains, occurring at their menstrual 
periods, which are followed and relieved by a gash of 
discharge ; and it is aaaumed that such pains are caused 
by collections of menstrual blood in the uterus, behind 
the supposed angle of flexion, the pain ceasing when the 
fluid finds an exit. This can hardly be taken as an 
argument seriously affecting the question at issue ; for 
first, it is, like all subjective symptoms, only to be ac- 
cepted with reserve; second, if the patient's account of 
her sensations be strictly accurate, it does not follow that 
this interpretation of them is correct; third, similar state- 
ments are made by patients who have no flexion ; fourth, 
the menstrual pain felt by the subjects of anteflexion is 
not always, but on the contrary, only seldom, thus de- 
scribed ; and last, while pain of this kind was at its 
greatest severity, the uterine sound has been passed with- 
out difficulty, and without its withdrawal being followed 
by ony discharge of blood.* 

II. Another clinical experience, which only demands 
notice because it has been often mentioned as evidence 
that the uterine canal was obstructed, is, that there has 
been diflicnlty in passing the sound. But there are too 
many ways of accounting for this for it to be at all 
demonstrative that the canal is at any point smaller than 
usual. The apparent obstraction may be due to want of 
dexterity on the part of the operator, or to the point of 
the sonnd catching in a fold of mucous membrane, or to 
the instrument not being bent in correspondence with the 
curve of the ntems. Whore narrowing of a canul is the 
condition which prevents an instrument from being easily 
passed through it, there is hindrance to the withdrawal, 
as well as to the introduction, of the instrument, especially 
if, like the nterine sound, its extremity is bulbous. I 
have never met with difficulty in the withdrawal of the 

■ SobulUe, ' Lij^everiiidcrBiigeii <l«r (Icb^mnttcr/ 18»1. S. oO. 



J 



ai4 



en TBBItKLATIOS OT UmrLKXtOB OT 



ordmaiy nteriue Bonnd (except where there 

tskable Btenosis from some other cftnee than anteSexion), 

nor bare I seen its occurrence recorded. 

HI. The clinic&l fact which has procured this theory 
such wide acceptance, is the nndeniably large number of 
cases of dysmeuorrfaoea in which the atems ig found ante- 
flexed. Many gynaecologista have pnblished statistics, 
compiled from their notebooks, showing in how large a 
proportion of cases they met with anteflexion, and how 
often it was associated with the different symptoms 
ascribed to it. But before we can conclude from the fre- 
quent co-existence of the phenomena in question, that 
because the utems is bent forward therefore the patients 
menstruate painfully, we mast know how often the bend- 
ing occurs without any alteration in the functious of the 
organ. The practice of an obstetric physician can never 
give this information, because the patients whom he 
examines come to him on account of some disorder of the 
genital organs, very often dysmenorrhoea ; he does not 
have an opportunity of examining women who think their 
uterine functions are naturally performed, and therefore 
he cannot tell in how many of them the uterus is flexed. 

Numerous investigations have been made, both post- 
mortem and during life, to determine the frequency of 
anteflexion, as well as of other displacements. In quoting 
them I shall for the sake of clearness and brevity only 
. cite that part of the figures which relates to anteflexion. 

Boulard* examined after death 27 adult nulliparous 
females, 19 female children between the ages of two and 
thirteen, 57 fcetuses at full term, and 4 premature footnaes, 
107 in all ; and in 98 of these he found anteflexion present. 
The exceptions to the rule consisted of 7 fcetuses and 2 
children. He came to the conclusion that " in the fcetus, 
tho young girl, and the woman who has not had children, 
the body and neck of the uterus have not tho same direc- 
tion i that it is not correct to say that the axis of the 
uterus i8 that of the pelvic inlet. The axis of the body 
■ ■ OazotU d<^ UaplUai,' 1853, p. 464. 



THE CTBEUS TO DYSMENOEROffiA. 215 

la almost horizontal, the neck only having the direction 
generally stated." Lorain* found in 25 fcetuaes, 6 ante- 
flexiona. Soudry,* out of 71 chiidreuj found 41 anteflexions. 
Goapil,* in 30 autopsies on ehildren, found 14 anteflexions. 

If these figures were the only information we had, it 
might be replied that, although anteflexion is natural in 
the foetus, yet at puberty the development which the 
nteruB undergoes causes the carve to disappear. But 
besides the fact that 27 of Boulard's cases were adults, in 
all of whom there was anteflexion, we have further the 
experience of Aran,-|- who in nine autopsies on virgins 
between the ages of seventeen and twenty-seven, found 6 
anteflexions, two of them being "most marked;" and in 
10 others who had not had children, there were G " very 
pronounced" anteflexions. Out of 61 antopsies made by 
Richet* on women who had not had children, he found the 
nteruB 33 times normal in position, and 11 times ante- 
flexed. 

Another objection which has been made to the foregoing 
figures is, that the anteflexion was in most of them a post- 
mortem change, Bonlard { I think sufficiently refuted 
this ; but there are other figures to which the criticism 
does not apply. There is a class of patients from whom 
we can got tho important lufurmation as to the frequency 
of anteflexion without, as well as with, uterine symptoms, 
those, viz. who seek treatmnnt, not for disordered function 
of the sexual organs, but for local contagious aSeo- 
tions. In these patients, while doing what is required for 
the local malady, the opportunity of ascertaining the shape 
of the uterus is given. Several French gyntecologists 
hare availed themselves of the field for research iu this 
direction afforded by the Lourcino Hospital in Paris. 

Depaul^ gives the result of his examination of 50 nulli- 
paroas women. In 32 of these the uterus was straight, 

' BerDDti and Ooiipil. op. cit., p. 4S7. 

t ' ArcliiraB Gfneralo* de MSdedne,' 1658, p. SIS. 

I Op. dL 

§ ' BnUotiD de I'AcadeiDio do Mudecine,' 18S3-4, p. SIO. 



216 



ON THE RBLATIOK OP ASTBFLKXION Of 



and coincided, or nearly bo, with tlie axis of tbe pelvic 
brim. In 7 there was anteversion, and in 3 cases the 
uterus was "manifestly" anteflexed. He does not say 
that none of these had been pregnant, bnt merely that 
they had not been mothers ; and he does not define what 
degree of bending he calls an anteflexion j but from the 
word " manifestly " (manifestement) one wonld infer that 
tolerably acote flexions are implied ; hence perhaps the 
comparatively small number that he records. Goaselin* 
inveatigated the same point on patients who had never 
been pregnant. Out of 45 cases he found 18 in which 
the uterus was "normal" in shape and position. In 16 
there was marked anteflexion, and in 11 slight anteflexion, 
Goupilf of 115 observations on healthy women, mostly at 
the Lonrcine, found 41 anteflexions, cases in which the 
body and cervix of the uterus formed an appreciable angle ; 
24 slight anterior curvatures, and only 19 in which the 
uterus was nearly or quite straight. PanasJ gives the 
result of 1 14 observations taken " with the greatest care " 
at the Lonrcine. He found among these 44 in which tha 
uterus was sti'aight, and 40 in which it was anteflexed. 
He comes to the conclasion that anteflexion in its different 
is a physiological condition in nearly one half of 
all cases; and that a uterus not bent, wrongly considered 
as the only physiological condition, only represents that 
of one third of the cases. 

Putting together the accounts of all those who have thoa 
investigated the shape of the uterus in adults who were 
not selected on account of their suffering from uterine 
symptoms, and who had not had children, we get the 
following figures : 

• ■Bulletin de I'AcBd^mie de MSdocine,' 1863-i, p. 640. 

t Bornut/ Bud Goupil, op. cit, p. 466. 

t 'Archives QiuBralea dc MedficlnB,' 1SG9, yoL L, p. 26*. 



TUE UTERD8 TO DYSMESOKRSffiA. 



Amn 


. 19 


Riolict . 


61 


D*p..ul . 


. 50 


Ooaaulia . 


. 45 


Goopil . 


. 115 


Panu 


. 114 


Total . 


. 431 



These totals appear to me to justify the conclusion of 
Panas. 

But from an examination of the figures ib will be 
evident that the inveatigatora from whose writings they 
are compiled, did not all agree in their defioitiou of an 
anteflexion. The difference between the report of Boulard, 
who in every one of twenty-seven cases found anteflexion 
present, and that of Depaol, who in fifty cases only found 
anteflexion three times, is too great to be due to fortuitous 
grouping together of cases of the same kind ; the probablo 
explanation is, that the observers differed as to the 
amount of anterior curve which in their opinion deserved 
the title of anteflexion. 

It the correctness of the figures be admitted, it may be 
said that, while a slight degree of anteflexion is so 
common as to be physiological, and may exist without 
symptoms, yot the more acute curves do interfere with 
function, and bring the patient to the obstetric physician. 
The accounts from which I have quoted contain nothing 
which is opposed to this view. 

Further investigations seemed to me wanted to deter- 
mine the frequency of the different degrees of anteflexion, 
and whether painful menstruation is more common in 
those women who have acute flexions of the uterus than 
in those in whom the organ is slightly or not at all bent. 

I have carried out this investigation on patients who 
were under treatment because they were suffering from 
local contagions diseases. Most of them were in the 
Female Lock Hospital, Harrow Road ; some were ia the 



218 ON THK GELATION OP ANTBFLKXION OP 

infirmary of the Wtitechapel Workhousej and some in 
the Venereal Ward of the London Hospital. I have to 
thank Mr. W. J. Coulson and Mr. Buxton ShiUitoe, 
surgeons to the Lock Hospital ; Dr. J. J. Ilott, resident 
medical officer to the Whitechapel Infirmary ; and my 
colleagues at the London Hospital, for permission to use 
their patients tor this inquiry. 

In order to reduce the problem to the simplest possible 
form, I rejected, for the inquiry, all patients who had 
had children or abortions ; for in them the pnerper&l 
process might have introduced other pathological elements. 
I rejected also all patients who were not menstrnating 
regularly, for in them the condition causing the amenor- 
rhtea might have produced other changes as well. There 
wore, of course, in some whom the local disease was of a 
kind which made vaginal examination undesirable ; and 
there were some who were suffering from perimetritia. 
But, with these exceptions, I took all just as they came, 
without any selection. To prevent any unconscious bias 
in my own mind from leading to error, I always, before 
rocordiug in my note-book the shape of tho womb, asked 
the gentleman in charge of the . case to give me his 
opinion, so that what I wrote down represented a state- 
ment in which two observers agreed. I have to thank 
Mr. G. H. Bishop, the house surgeon of the Lock Hos- 
pital, Dr. Hott, and my resident accoucheurs at the London 
Hospital, Mr. Lloyd Francis, Mr. C. E. Jennings, and Mr, 
Fenton Jones, for thus helping me to make my observa- 
tions accurate. In describing the shape of the utems, 
the terms used were, that it was either straight or bent 
at an obtuse angle, at a right angle, or at an acute angle. 
Tho first term needs no explanation. The latter means, 
not that the flexion was supposed to form an angle, but 
that the uterus was so bent that a line continuous with 
the axis of the upper part of the uterine body would 
form, with one continuous with the axis of the lower part 
of the oervix, an obtuse, right, or acute angle aB the 
case might be. In the cases, which were few in number. 




L 



THE CXEEU8 TO DTSMEN0KRO<EA, 219 

in which we did not agree as to the term most correct, I 
set dowu at the time the difference of opinion, thus, right 
or acute, obtuse or right, &c. In subsequently tabulating 
them I have taken the lower estimate of the degree of 
flexion, e.g. one put down as right or acute I have 
classified as flexed at a right angle. I think, therefore, 
that 1 have taken every precaution that I could have 
taken to prevent any unconsciouB bias of my own mind 
from leading me to wrongly estimate the facts. 

I have examined 111 women who had never been 
pregnant, who were menstruating regularly, and who 
submitted to examination not for uterine disease, but for 
local contagious disorders. Of these, in 43 the uterus 
was as nearly as possible straight. In 14 there was 
slight anteflexion, so that the neck of the uterus seemed to 
form with the body an obtuse angle. In 30 the uterus 
was BO much bent forward that the neck formed with the 
body a right angle ; and in 23 the anteflexion was at an 
acute angle. 

In short, out of 111 patients, pronounced anteflesinn 
was present in 53, or 47"7 per cent. 

(For the sake of completeness, I may parenthetically 
mention that in two cases there was retroversion, but the 
axis of the uterus was nearly or quite straight, and the cases 
are put under that head ; and in one there was retroflexion ; 
this case is not included iu the figures which follow). 

The proportion of anteflexions which my investigation 
revealed ^rees so closely with the figures I have quoted 
from other authors, that I think all of them together 
.justify the assertion that in nearly half of all nulliparovs 
women the uterus is antcficxeii. 

The fact, however, that anteflexion is exceedingly 
common is no proof that it does not caase menstrual 
pain. It may be asserted that although the slighter 
forms are insignificant, yet that the more acute flexions 
cause suffering. It may also be said that a flexed 
uterus which may give no trouble so long as its owner 
remains single, may yet, when subjected to the altered 



2ZU ON THE RELATION OF ANTEFLEXION OP 

functional conditions involved in marriage, give rise 1 
painful symptoms. 

To find out wliether the frequency of dysmenorrhoea 
corresponded to the degree of the bending, I inquired as 
to the amount of tho menstraal pain of each of the 111 
women that I examined. I took great care not to put 
leading questions, and I made a point of writing down 
the shape of the uterus before I inquired about the pain. 
The patients were asked first whether they suffered pain 
or not when they were unwell. Those that said they 
had paiU) were further asked whether the pain was only 
slight, or was very bad, and if they said it was very bad, 
inquiry was made as to whether they were laid up at the 
menstrual period or not. They were thus divided, in 
respect of pain, into four classes 1. Those that had no 
pain. 2. Those that had slight pain. 3. Those that had 
severe pain ; and 4, those whose pain was so bad as to 
compel them to lie up. 

The following is the result of the investigation : 
Of the 43 patients in whom the uterus waa nearly or 
quite straight, 

16 menstruated without pain. 
16 „ with slight pain. 

7 „ with much pain. 

5 „ with pain so bad 

Of the 14 cases in which tlie 
anteflexed, 

4 menstruated without pain. 

5 „ with slight pain, 

2 „ with much pain, 

3 „ with pain so bad a 
Of the 30 cases in which the uterus was antoflexed at 

about a right angle, 

12 menstruated without pain. 
9 „ with slight pain. 

7 „ with much pain. 

2 „ with pain so bad as to lay them up. 



as to lay them up. 

uterus was slightly 



3 to lay them up. 



Of the 23 cases in which the anteflexion was acute, 
10 meiistraated without pain. 

6 J, with slight pain. 

4 ,j with much pain. 

3 „ with pain so bad aa to Iny them up. 

Patting them together bo as to show the facts in a 
broader way, it is found that out of 57 women in whom 
the uteras waa only slightly or not at all flexed, in 40, or 
70 per cent., there was tittle or no pain at the menstrual 
period ; and in 17, or 29 per cent., there was severe pain. 
Ont of 53 women in whom there was pronounced ante- 
flexion, in 37, or 69 per cent.^ there was little or no pain 
at the menstrual period; and in Id, or 30 per cent., there 
was severe pain. 

Classifying them diSerentlj, so as to show what influ- 
ence the acutencss of the flexion has, it is found that oul 
of 23 oases with acute anteBexion, in 16, or 695 per 
cent., there was little or no menstrual pain ; in 7, or 30-1 
per cent., severe pain. Out of 87 others, in whom such 
anteflexion as was present was not acute, in 61, or 701 
per cent,, there was little or no menstraal pain ; in 26, or 
29 '8 per cent,, severe pain. 

The differences between these two sets of figures are 
BO trifling that I think them practically nil. The figures 
show two broad facts: — 1. That menstruation is as often 
painful when the uterus is straight as when it is ante- 
flexed. 2. That it is aa common for mensti*uation to 
be painless when the nterus ia anteflexed aa when it is 
not anteflexed. 

With regard to the view that married life might cause 
the development of symptoms in an anteflexed uterus, I 
would say, that most of the subjects of my investigation 
were prostitutes ; and one would think that whatever 
injurioua effect upon the se:tual organs ordinary marital 
intercourse might have, would also result, bat much 
intensified, from the mode of life of a prostitute. 

It seoma to me that the facta point clearly to the 



223 ON THK BELATIOH OF ANTZFLEXIOM O* 

inference that the degree of bending forward of the nterus 
does not appreciably influance the presencs or severity of 
menstrjtal pain. 

TV. The last method of proof whicli is possible is that 
from the effect oj treatment' 

If anteflexion generally cauaea dysmenorrhoaa, it ought 
to be the case (1) that, as a rule, all treatment o£ each 
dysmenorrboja which does not straighten the nterns 
should be inefiicient ; and (2) that treatment which does 
straighten the uterua should as a rule be succoasful. I 
insert the words " as a rnle " because clinically cases are 
often complicated, and general assertions, true of simple 
cases, may not hold good when applied to a combination 
of moPbid conditions. 

1. The distinguished physician to whose able advocacy 
and high reputation the wide acceptance of the mechanical 
fheory of uterine pathology is mainly due, has advocated 
rest in the recumbent posture as the " first principle of 
treatment "* in anteflexion. However useful this treat- 
ment may be, and whatever its efficiency in straightening 
the uterus, there are so many morbid processes which 
tend to recovery when the patient is kept at rest, that 
the disappearance of symptoms under this regimen can 
hardly be held to be conclusive as to their origin. 

2. Dr. Graily Hewitt has also invented for the treat- 
ment of anteflexion a most useful pessary, the "cradle." 
I have not seen any statement of the frequency with 
which benefit to dysmenorrboea bas followed its use. I 
have known menstrual pain diminish and cease while the 
patient was wearing one of these pessaries. But I have 
never found the uterus straightened while it was being 
worn. I do not think the oases are many in which it will 
remove dysmenorrboea ; but when it does so, it is without 
straightening the uterus. 

3. It is well established that there are cases in which 
enlargement of the cervical canal by incision cures dys- 
luenorrhcoa. Actiug on the theory that dysmenorrboea 

• 'Oltet. Trniisacliou*,' vol. nii, p. 176. 



TBR CTEHU8 TO OISHBN0EEH(EA, 223 

occurring with anteflexion is due to narrowing of the canal 
owing to the bending. Dr. Marion Sims has planned an 
operation in which the incisions are so directed that, if 
extensive enough, they would make the canal straight. I 
have not seen any published cases showing the result of 
that operation, and what proportion of cases it relieves ; 
but it is quoted with approbation by several distinguished 
compatriots of the author ; and it is scarcely conceivable 
either that they would adopt, or that a man so eminent as 
Dr. Sims would promulgate, an operation which had never 
been followed by at least apparent benefit. But any one 
who will examine a section of an acutely anteflexed uterus 
will see that it is impossible by incision to obliterate the 
bend of the canal, except by catting so deeply as to reach 
either bladder, or peritoneum, or both. This anatomical 
argument applies only to the fresh incisions ; after they 
have healed, the space gained by them would be much 
less than when recently made. An operation in which 
the incisions were no deeper than they could bo safely 
made, if it widened the canal, would not make it straight ; 
and cicatrization would restore it nearly, if not quite, to 
its former condition. Therefore, Dr. Sims's operation, if 
snccessful, is an instance of the cure of dysmenorrhQca 
with anteflexion without straightening the uterus. 

4. It is well known that there are cases of dysme- 
Dorrh<£a in which benefit follows dilatation of the uterine 
canal, either by bougies, tents, or an expanding sound. 
This has been claimed as evidence that the anteflexion is 
the cause of the dysmenorrhcea, it being assumed that the 
effect of the dilatation is simply mechanical, that there is 
stenosis, and that the anteflexion is the cause of the 
stenosis. It is impossible here to discnss this very wide 
subject. I will therefore confine myself to stating the 
objections to this theory, which are t {!) That the thera- 
peatic eSect of dilatation is not proportionate to the 
amount of resistance encountered by the dilating agent. 
(2) That dyamenorrhoia, removable by dilatation, is luot 
with when the uterus is straight as well as when it is bent. 



224 ON THl EHLATION OF ANTEFLBXION 09 

and (3) that the anteflexed uterna remains nearly or qnito 
as much beut after the dilatation as before it. 

6, There is one agent which can, beyond question, 
straighten an anteflesed nterus, viz. the intra-uterine stem. 
There is no doubt that in some casea menstrual pain is 
relieved by the ose of these instruments, but their effect 
is not confined to the straightening of the uterus. It ia 
well known that when an instrument just filling the cer- 
Tical canal is left there the canal soon dilates, so that the 
instrument fits loosely. The intra-uterine stem is there- 
fore a dilator of the cervical canal as well as a straightener 
of the uterus. Besides this, it irritates the organ, causes 
a determination of blood to it, and usually more or less 
endometritis. So common an effect is this, that one 
advocate of the intra-nterino stem has said that he looks ' 
upon the occurrence of haemorrhage and free discharge as 
a favorable sign. It is possible that this stimulant or 
irritant effect (whichever term be preferred) may in some 
cases do good. There is yet another source of fallacy. 
Those who advise the use of atom pessaries lay much stress 
on properly preparing the uterus, eo that it may tolerate 
the instrument; this preparation consisting in the removal 
of all inflammation or congestion of the pelvic organs. 
Seeing how frequent anteflexion is, it is to be expected 
that, unless it were a prophylactic against these conditions, 
it would often be associated with them. It may possibly 
be sometimes the case that benefit seemiug to follow the 
wearing of an lutra-uteriue stem is really duo, not to the 
instrument, but to the careful preparatory treatment. 
Benefit following the wearing of the iutra-uteriue stem 
may have been due to any one of these three causes, 
or to the combination of thom, and not have resulted 
from the straightening of the uterus. But if it be 
true that anteflexion generally causes menstruation to bo 
painful, then the stem pessary, when well tolerated by 
the nterus, ought to remove the pain as constantly as it 
without doubt removes the flexion : and in cases of dys- 
meuorrhcua with anttifluxiun, iu which the removal of cod- 



I 

I 



THE OTtEOa TO DYSMENOREHiEA, HaO 

gestion, vaginal pesaariea, dilatation, incision {methods of 
treatment which do not remove anteflexion), have boon 
tried in vain, the intra-utcriHe stem ought to be almost 
invariably auccoRsful. 

Unfortunately, the literataro of the snbject does not 
furnish any scientific statement of the frequency with 
which intra-nterine stems cure dysmenorrhoea associated 
with anteflexion. Nearly all authors who have written 
upon the subject have given only their general impression 
as to what is the usual result ; they have not givou their 
experience in full. Some gyoEecologista of ability have 
thought that they saw much benefit fromintra-uterinestems; 
others, of equal eminence, have condemned the instrn- 
ment altogether. These general statements seem to me likely 
to be erroneous, for this reason, that an individual observer 
tends to see an undue proportion of the cases in which his 
own treatment has been successful and that of others 
unBUCceEsful ; for those patients to whom he has done 
good continue to consult him, while those for whom his 
treatment has been unsuccesAful lose confidence in him, 
and go to some one else. The only way to avoid this 
aonrceof error is to carefully record every case, so that 
not only the number of case.s cared may be known, but 
the number of those in whom treatment of the same kind 
was unsuccessful, was impracticable, or the patient was 
lost sight of, I cannot find any author who has done this 
in a way that bears materially on the present question; 
the cases published in detail are too few to be of use, and 
those writers who have given their experience in figures 
do not isolate the cases in which the stem was used for 
dysmenorrhoja with anteflexion from those in which it 
was resorted to for different conditions and symptoms. I 
am obliged, therefore, to say that wo have no information 
as to the frequency with which straightening the uterus 
with an intra-uterine stem cures dyaraenorrhtEa associated 
with anteflexion. I do not think it worth while to give 
my own experience, because, knowing that these instru- 
ments are attended with some risk, and doubting their 

VOL. zsiit. 15 



226 ON THE RELATION OF ANTEFLEXION OP 

utility, I have only employed them in a few cases in 
which many other kinds of treatment had failed; and it 
might bo said that it is not fair to test any treatment by 
cases selected for their incurability. 

I cannot but regard the extreme differences of opinion 
that still exist as to an iostrument which has now been 
before the profession for more than fifty years, as in them- 
selves very important. The dangers which are believed to 
accompany it seem to me no adequate explanation of the 
disfavour with which many regard it. If it were as uni- 
formly successful as by the theory of its action it ought 
to bCj its efficiency as a means of a cure would long since 
have been acknowledged. There might still be differences 
of opinion as to its safety, or as to whether the malady 
was enough to make it worth the patient's while to incur 
the risk of possible ill consequences, but there would be 
no dispute as to the efficacy of the stem in removing men- 
strual pain. 

The general conclusioos, then, which I draw from the 
effect of treatment, are these : 

(1) That dyemenorrhcea associated with anteSezion ia 
frequently cured without straightening the uterus. 

(2) That straightening the uterus does not invariably 
cure the dysmenorrhoDa, and that there is no evidence that 
it does so frequently. 

In Bnmming up the purport of this paper, I would 
submit to the Society the following propositions : 

1. That there is no anatomical evidence that anteflexion 
causes any appreciable hindrance to the escape of men- 
strual fluid. 

2. That there is reason to think that well-marked aute- 
tiesion is present in nearly half of all women who have not 
borne children. 

S. That therefore it is to be expected that anteflexion 
and dysmenorrhcea would frequently coincide, 

4. That dysmenorrhcea is practically as common when 
the uterus is straight as when it is anteflexed. 



THE triKBUS TO DY8MEK0R14H0:A 



227 



5. That pftinlesa menstraation is practically as common 
when the uterus is antciSexed as when it is not. 

6. That when djamenorrhfBa and fleiion go together, 
the severity of the pain bears no relation to the degree of 
the bending, 

7. That dysmenorrhcea associated with anteflexion Is 
frequently cured without straightening the uterus. 

8. That there is no evidence that straightening the uterus 
inTarlably, or even frequently, removes dysmenorrhcea 
which is associated with anteflexion, and in which other 
methods of cure have been inefEectual, 

9. That these facts tend to show that th§ relation 
between anteflexion and painful menstruation is not that 
of cause and efEect, but merely that of coincidence. 



APPENDIX. 

In the discussion which followed the reading of this 
paper, one speaker alluded to the fact, which he considered 
important, that most of the patients were prostitutes. I 
have therefore thought it well to give the exact numbers, 
and the ages of the patients, which may also be of interest. 



Age . .14 


1616 

1 


17 


1819 


20 


i\ 


iZ 


" 


34 


3S 


1 
3827 

1 


32 


"\Tr 


Prortltute. . .' 

NotnusbordODbtfU 1 

1 


1 


2 
1 


10 
10 


1616 

1 


2 
8 


7 

4 


i 



2 


i 
3 


1 


l' 1 



1 


ij 


68 
42 


Total . . 1 


' 


8 


» 


Jso 


6 


11 


* 


' 


5 


I 


1 1 


2 


ij,|, 


110 



The following were the occnpetions of some of thoae 
who were not prostitutes : — General servants 1 7, laandresses 



228 ON THE &ELATIOK OF ANTKFLESION OP 

3, married 3, living in concnbiunge 2, shop-girls 2, barmaids 
2, housemaids 2, parlourmaid 1, dressmaker I, ironer 1, 
matchmaker 1. Of the occupations of the others lean get 
at no record. 



Dr. Oebtib, aft£r expressing his admiration of tlie care and 
ability which charaeteriaed Dr. Herman's communication, Ten- 
tured to doubt whether his deductions were entirely valid, even 
if his facts remained unchallenged. He belioTed it to be quite 
possible for even a flexion of the uterus to exist and yet no ob- 
stmction to be produced, provided the calibre of the cervical 
canal were not intruded upon by the hend. For example, in the 
specimen iZ the College of Sur^^ns' Museum, to which the author 
referred, the other half of which was in the St. Thomas's Museum, 
there was no obstruction in the utero-cerrical canal, although a 
very marked curvature was present. And, indeed, it was a ques- 
tion whether between cases of sharp fleiion on the one hand and 
cases of simple uterine version on the other, it would not be well 
to recc^ise an intermediate class of cases of antecurvature, in 
which, with the bend forward, there was not necessarily any 
obstruction, and to which probably Dr. Herman's cases of ante- 
deiion without symptoms would mostly belong. He (Dr. 
Qervis), however, still held to the belief that if there were 
obstruction in the cervical canal, however produced, there would 
result the symptoma characterising obstructive dysmenorrhcea, 
although the mere position of the uterus, apart from the obstruc- 
tioD, he thought of small importance. 

Dr. AvKLiNG asked Dr. Herman what method he had adopted 
in discovering the amount of displacement, and in distinguishing 
between anteflexion and anteversion ; also whether the condi- 
tion of the bladder had been considered in each case? Dr. 
Aveling thought anteflfxion was the cause of obstruction resulting 
not only in dysnienorrhoea but in sterility. 

Dr, Herua.1i explained that he estimated the anteflexion by 
bimanual examination. 

Dr. GiLABitr thought that great credit was due to Dr. Her- 
man for the scientific manner in which he had endeavoured to 
approach the solution of this controverted question. But there 
was one consideration which diminished the convincing effect of 
all such statistics, namely, that if we knew the previous opinions 
of an author bis statistical inquiries invariably come out in sup- 
port of those opinions. The recent statistics of Dr. Graily 
Hewitt on the relation of uterine flexion to hysteria would, if 
accepted as free from anv Influence of unconscious bias, demon- 
strate as completely the extreme importance of anteflexion as 



THE UTEEC8 TO J)Y8MEN0RBeCE4. 



229 



J of Dr. Herman would, on a similar hjpotbesia, have 
demonstrated the contrary. Again, Dr. Emmet had published 
the statiatica of many hundred e&seR, from which he inferred that 
fleiioa of the uterine body was, in all coses, associated with 
paiu during the menstrual flow, lie thought that Dr. Her- 
man's argument was, in some points, open to criticism. He 
made no dietinetion iii his statistics between congestive and 
obstructive dysmenorrhcea, whereas it wus perfectly easy to dis- 
tinguish, by the time of the pains, between a certainly congestive 
dyamenorrhtea and one which was or might be obatmctive. If 
it were true, as held by Schultze, that permanent straightnesa of 
the nutliparous uterus is by itself a proof of induration from 
chronic metritis, these statistics would be quite intelligible, even 
though anteflexion were a frequent cause of obstruetire dysme- 
norrhoea, for congestive dysmenorrhma might be commoner among 
the straight uteri. Again, it was a drawback that the statistics 
were taken from prostitutes who had probably all, or nearly all, 
had gonorrhoea, and could hardly have escaped uterijie congestion 
and endowetritiii. He thought that in general the congestive 
basis of djsmenorrhtea prepondcnit«d over the obstructive, and, 
among prostitutes, the preponderance might well be so groat that 
all clue might be lost to the causation of obstructive dysmenor- 
rhcea in statistics iu which both forms were massed together 
indiscriminately. Dr. Herman based a main part of his argu- 
ment upon no anatomical evidence of obstruction having been 
produced, and the evidence be demanded was that a distended 
uterus should be shown at autopsies. But surely it was contrary 
to all physiological analogy to expect any such thing. In stric- 
ture of the male urethra, unless there were absolute closure, we 
found not a distended bladder, but a contracted bladder with 
thick walls, even though such a bladder were unable to empty 
itself completely. A fortiori the utenis, having thicker walls iu 
proportion, would become hypertrophied if necessary, to resist 
permanent distension. Thus we did not find it distended in 
even extreme stenosis of the canal. The only anatomical evi- 
dence of obstruction we could possibly expect was enlargement 
of the uterus from thickening of its walls, and this did not uo- 
ti^quently coexist with anteflexion, though absent often enough 
to show, OS he thought, that anttflexiou did not necessarily pro- 
duce any perceptible obstruction. He thought the four cases of 
preserved uteri cited by Dr. Herman, which might have been 
coses of congenital anteflexion, insufficient to prove that ante- 
flexion never caused any obstruction. This question should 
rather be settled by examination of the fresh ut«rus. Making an 
antero-posterior section of a fresh-flexed uterus, he bad found 
that bending it a little more flattened the canal, while straighton- 
ing it a little separated the anterior and posterior w<ills. If sus- 
pended in a bottle by the fundus, the effect of gravity would tend 



230 



ON THB RELATION OF ANTEFLBXION OF 



to etrai^'hten the organ a little, obliterate an^ flattening of the 
canal even if it existed, and tbe ut€rus would become hardened 
in this condition. It seemed to him so obvious as to be self- 
evident that if a straight canal, having flaccid rather than stiff 
walls, were bent, its calibre nould be diminished. Impediment 
might thus be produced, if not to perfectly fluid blood, jet to 
clots or shreds of membrane. If the canal were originally 
cmred tbe case would be different. He was astonished that Dr. 
Herman found strongly marked anteflexion in nearly 50 per 
cent, of his cases. His own experience, in the case of virgins who 
came for treatment for amenorrhcea, would agree more nearly 
with that of Professor Depaul, who found only 6 per cent. He 
thought that the discrepancy might be explained when he heard 
that Dr. Herman examined solely by the bimanual method. Dr. 
Herman's statistics might perhaps apply, not so much to uteri, 
which actually had a marked anteflexion, as to those which could 
be brought into such a condition by pressure from above. 

I>r. Hetwood Smith thought Dr. Herman had rather exag- 
gerated the description of the conditions of the uterine canal in 
cases of anteflexion in saying that there existed a spur of tissue 
projecting backwards into tbe canal. Ho would refer in proof 
of the antecurve of the fcetal uterus, to a flue section of the 
whole pelvis of the fcetus in the museum of the Hospital for 
Women, where it would be seen that the whole uterus is 
gradually and evenly curved forwards. With regard to Marion 
Sims' operation, it was not intended as a means of straightening 
the uterus, but of cutting as it were a new and straight canal. 
He agreed with Dr. Herman as to the frequency of the association 
of sterility with anteflexion, but his explanation of that condition 
was, not that the uterine canal was constricied, but that the 
flexion elevated the os uteri forwards up against the pubes, so 
that it was lifted above the pond of seminal fluid that gravi- 
tated into the posterior cul-di;-eae of the vagina in the supine 
position. There was no doubt but that iu many cases, as Dr. 
Braxton Hicks observed, frequent reposition of the uterus and 
the passing of a thick uterine sound led to immediate relief of 
the dysmenorrhceal symptoms. Then, with regard to the hiatoiy 
of the case, patients with anteflexion described the pain, wbiob 
was quite characteristic, as preceding the flow, and i-eferred it 
to the hypogastrium, and as being of a distinctly bearing down 
and forcing character. 

The Feesident complimented Dr. Herman on the excellence 
of the method which he bad pursued in the study of the subject. 
It was a great point in his demonstration that the dilated 
uterus and the spur-like obstruction at the internal os, so 
frequently depicted, were never seen. No such specimen was 
described except from imagination, — none was found in mu- 
seums. Specimens well described showed no dilatation of the 



THE UTBR08 TO DTSHENOBBHOSA. 



231 



i 



uterine carity and no spur ; and he (Dr, Duncan) believed 
there wa^ no obatruction. By statistics and by a masa of other 
evidence, Dr. Herman had brought his opinions iax nearer to proof 
than those hul done who held other views. Much had been 
made of the condition of supposed obstruction. Now, a e]>ecimen 
of anteflexion with complete atresia or closure of the cervical 
canal was shown by him lately to the Society, aud in it there was no 
spur aud no dilatation of the uterine cavity. If there waa only 
a small or very contracted passage, there was still room enough 
for blood to pass freely, not only the few ounces in a few days 
of a menstrual period, but so much as to let the wumu,n bleed 
to death in a very short time. Along with Dr. Gamgee he bad, 
some years ago, published a paper in the ' Journal o£ Anatomy 
and Physiology,' showing the facility of the passage of blood 
through capillary canals, and there was much clinical evidence to 
the same effect. 

Dr. Hekhan, in reply, said that he had not disputed the 
evidence of obstructive dyamenorrhiea. But if it were admitted 
that there was obstruction, it did not follow that the obstruction 
was due to flexion. He was quite aware that in estimating such 
points as the degree of flexion, preconceived opinions were apt to 
unconsciously bias the investigator. He bad stated in his paper 
the precautions he had taken to prevent any such bias in his 
own mind from affecting the result. Dr. Hewitt's paper, to 
which Dr. Galabin had referred, only showed that a number of 
invalids got well under the influence of rest and good diet. He 
(Dr. Herman) did not think that was enough to prove thai their 
symptoms were due to anteflexion. Dr. Emmett's statistics did not 
bear on the question ; for this author found anteflexion frequently 
associated with dysmenorrhcea, because he only examined patienU 
who consulted him for some uterine trouble. Dr. Herman was 
aware that there were other kinde of dysmenorrhcea besides that 
sup|K>sed to be due to flexion ; and it was possible that some of 
those whom be examined, being prostitutes, might have bad 
dysmenorrhcea from some uterine or ovarian condition brought 
about by their mode of hfe. This being fully admitted, if it 
were the fact that anteflexion caused dysmenorrhcea, there still 
ought to have been a decided preponderance in the frequency of 
dysmenorrhcea among -those whose uteri were anteflexed. In 
saying that stenosis of the canal should lead to dilatation of the 
uterine cavity, be hod only quoted what was stated and shown 
diagrammatically in many books ; and the terms" spur" or "pro- 
montory " were not his own, but were used in works of high 
repute. Theoretically, of course, it was the fact that fluid would 
a little more readily along a straight tube than along a 
curved one ; but taking mto consideration the shape and size of 
the uterine canal, the amount of fluid that had to flow throueh 
it, and the length of time allowed for that flow to take place, the 



232 BBLATION or AHTEFLRXIOH TO DT81ieN0RBBaCA. 

mechanical difference would only amount to some iBfinitesimoJ 
fraction ; it was not appreciable. It was very rarely possible to 
distinguish congenital &om acquired anteflexions ; it antefiexion 
were found, how could we tell (unless the patient had been 
examined at some previous time) that it had not been the ca»e 
from the beginning ? He did not know any way of diagnosing 
anteflexion so certain as bimanual examination. He did not 
think that in his cases the anteflexion had been produced by the 
method of examination; if it were bo, it was reroiukable that his 
figures should so nearly agree with those of other inTestigators, 



NOVEMBER 2nd, 1881. 

J. Matthkws Duncan, M.D., F,R.S. Ed., President, in 
the Chair. 

Present — 54 Fellows and G visitors. 

Books were presented by M. H. Vanden Bosch, Dr. W. 
L. Richardson, Dr. Edw. T. Reichert, and the Obstetrical 

Society of Boston. 

Herbert G. Cronk, M.B , was admitted a Fellow of the 
Society, and Jas, 6. Creasy, M.R.C.S. (of Brasted), was 
declared admitted. 

The following gentlemen were elected Fellows : — Wm. 
Alex. Hepburn, F.Fac.P.S. Glaa. (Coshoe, Durham); 
Arthur Perigal, M.D. (New Barnet) ; Archibald Sloan, 
M.B. (Glasgow), and Francis P. Taylor, F.R.C.S. Ed. 
(Prince Edward Island). 



REMOVAL OF A LARGE FIBROUS POLYPUS. 

By HsrwouD Shith, M.D. 

M. H — , Kt. 35, single. Was admitted into the Hos- 
pital for Women, October 6th, 1881. Catamenia com- 
menced at 12^ years, regular, lasts seven days with pain; 
latterly pain in sacrnm and hypogastrtum for three days 
previously. 



231 



BEUOTAL OF A LAEflB FIBKOUS POLTPDS. 



Five years ago she began to have menorrhagia with 
sacral pain and bearing down in the hypogastrium. Be- 
tween the periods she had leucorrhea which has gradu- 
ally increased. This went on for two years before she 
conanlted a doctor. She waa under his eare for twelve 
months. Three years ago she began to have pain in the 
right aide which has increased at each period. For the 
last twelve months the catamenia have been profusej and 
»he noticed the abdomen enlarging; occasionally she has 
had difBculty iu micturition. 

On admission she was in fair condition, but very much 
blanched. In the hypogastrium a hard tumour presented, 
reaching more than half way to the nmbiticua. Vaginal 
examination : about one and a half inch from the vulval 
ori6ce a hard tnmoor presented, rather pointed towards 
the outlet ; it looked mottled, and pitted slightly on 
pressure. It was impossible to reach more than half 
way up the tumour, which distended the vagina so that 
its walls seemed tightly stretched. The sound appeared to 
pass higher on one side than the other, but the cervii 
could not by any possibility, even with the help of an 
auiesthetic, be reached. The diagnosis was a fibrouB 
polypus, and its removal was determined on. 

The followiug operation waa performed on October 13th. 
The patient being placed under bichloride of methyline, 
an attempt was again made to reach the cervix uteri, 
but unsuccessfully. A steel wire (jcraseur was then 
passed, and several incffeotnal attempts having been made 
to get the loop beyond the widest circumference of the 
tumour, about a quarter of the mass was encircled and 
cut off J then, in order to arrest the hsemorrhage, the cut 
surface waa seized with a pair of strong forceps, and the 
steel loop again passed over the tumour; as there waa 
atill considerable difficulty in the manipulation, and the 
perineum seemed likely to give way, it was divided freely 
with a scalpel down to the sphincter ani. The wire waa 
then pushed higher up and tightened, when it was felt to 
have slipped up and to bo constricting the neck of the 



REMOVAL Off A LARGE FIBROUS FOLTPUS. 235 

polypus. The pedicle was then cut through and the 
tumour was free in the vagiua. The author's tumour- 
forcepa were then applied and strong compresBiou exer- 
cised, yet though the divided perineum gave more room, 
it was found impossible to extract the tumour. The 
ecraseur was therefore applied again and the tumour cut 
into three portions, which were easily removed. The 
cervix was found fairly healthy; the stump of the pedicle, 
which was just inside the posterior margin of the os, was 
cauterised ; the edges of the divided perineum were 
brought together with three silkworm sutures ; the 
vagina plugged with matico and carbolised oil, and the 
patient put to bed. During the operation the assistant 
broke two strong steel wires in trying to get them 
through the slot of an ordinary ficraseur, thereby demon- 
strating the value of the author's modification which 
allows of the head of the 6craseur being opened in order 
to receive the loop without its being bent into so sharp 
an angle as is necessary for its passage through the slot. 

The next day the temperature reached 103° F. at 3.30 
p.m., after which it gradually subsided. The tumour 
weighed 1 lb. 10 oz. The stitches were removed from 
the perineum on the fifth day, and on the eighth day the 
perineum was found completely healed. On October 
28th the cervix was examined and found natural, and the 
uterine sound passed two and a half inches. The abdo- 
minal tumour had entirely disappeared, 

Hemarht. — This case ia an instructive one as showing 
the danger to the patient's life both from the h»Bmor- 
rhage, and from the increased danger of the operation 
that resulted from the nature of the tumour remaining so 
long unrecognised. Much of the pain arose doubtlesa 
from the extreme tension of the vaginal walls; this, too, 
was a source of danger, as the necessary manipulations 
might have caused their rupture. Difficulty and danger 
also existed from the necessity of operating without any 
information being possible as to the situstion of the 
cervix uteri. The history helped to exclude the proba- 



236 RBMOYAL OP A LABaS FIBR0D3 POLYPUS. 

bility of the tumour being the inverted uterua. Another 
feature of interest was the impoasibUity of removing the 
tumour whole from the vagiua, and the deliberate division 
of the periupum to facilitate the removal. 



Dr. MuBRA-T having seen the same accident occur at the time 
of removal of the tumour, he vouid certainly advise the slicing' 
or otherwise diminishing the mass before extirpation. The case 
was under Dr. Carter's caro at the Soho Hospital, and presented 
very many difficulties at the onset of and during the operation, 
but subsequently did well. 

Dr. Baenes thought the course pursued by Dr. Smith in 
dividing the perineum by incision was the right one. In a 
similar case which he had witnessed, the perineum was torn, and 
his impression was that the wound became a main factor in fatal 
septictemia. When we divided the perineum by the knife wo 
made a clean wound in accordance with our design, and it could 
be closed afterwards by sutures. 

Dr. EoTJTH said he remembered a case which he had seen 
and treated — a patient of the late Mr. Isaac Baker Brown, when 
that gentleman was ill. The fibroid filled the vagina and 
reochra up to the umbilicus. Mr. Brown had diagnosed this 
tumour as enlarged uterus, because on passing the finger just 
within the vagina, one came against a depression like the os uteri, 
and beyond there seemed an ajierture, into which a souud could 
be passed several inches up. With great difficulty he (Dr. Bouth) 
managed to feel a small portion of the rim of the os uteri very 
high up, and so made out the true nature of the case. He passed 
up, with great difficulty, a wire i^raseur,aud cuttbrough a large 
portion, but it could not bo extracted fi-om the vagina till it had 
been sUced in several pieces. The case went on for several 
days pretty well, when tetanus came on, of which she died. This 
mishap he believed was unique after operations on fibroids, and 
the only one he had seen in forty years' practice. In referring 
to Dr. Barnes' remarks on his case, it was very true that in olden 
times many cases of polypi which were tied and left to slough off 
in the vagina, even under so experienced a practitioner as ihe 
late Dr. Robert Lee, died from septieiemia before the separation 
had occurred. But in those days no vaginal washings with anti- 
septics were carried out, si)ecially with iodine. But in Dr. 
Barnes' case the tumour was removed, not left to putrify ia til&, 
and possibly vaginal washings had l)een employed. But Dr. 
Barnes had not stated that the torn perineum had been sewn 
up, a measure which should always be carried out, whether the 
perineum had been torn or cut. If this was not done, this 



REMOTiL OP A LAROK FIBBOrS POLYPUS. 



237 



simple omiasioa was probably the cause of death, the torn parts 
being very obaoiioua to infection by septic vaginal dischai^a, 

Dr AvBiiwa thought there could be little difference of opinion 
among the Fellows as to the propriety of incising the perineum 
when there was fear of laceration, whether from the passage of 
the foetal head or a tumour; be would suggest, however, that it 
might be better to make the incisions JatCTally. 

Dr. Wtnn Williams remarked that implicit confidence could 
not be placed in Dr. Heywood Smith's ecraseur, as in a case 
where he had to remove a very large fibroid tumour, whilst 
tightening the wire, the rivet on which the square button 
worked broke, and as he was many miles in the country he had 
to return to the town, where he found an ingenious watch-maker 
who tired the button with rivets, in fact, made it into an ordinary 
ijeraseur. On the following day he removed the turaoiir, which 
was several pounds in weight, in four pieces, one after the other. 
If, therefore, any one desires to use Dr. Hey wood Smith's instru- 
ment, he would recommend him to be supplied with another in 
case of accident. 

Dr. WiLTsaiEE thought the perineum should very rarely bo 
torn or incised during the removal of large uterine fibroids. The 
growths might be so diminished by cutting portions away, either 
in wedge-shaped masses or othtrwise, as to render injur; to the 
{>erineum, as a. rule, unnecessary. If incision were imperative he 
preferred the lateral incision. Tearing of the parts was undesir- 
able. Comparison with the parturient perineum was hardlv 
accurate, for during labour the parts were more dilatable. Much 
might be done by steady and patient traction corabiued with 
diminution of the fibroids. 

The President bad known great lacerations of the perineum 
to occur in removing fibroids, even through the sphincter. 
If great laceration was expected, be would prefer incision 
to avoid laceration ; but if only a little laceration, as was 
usual, was expected, then be would prefer that the perineum 
should take its chance, thus probably securing the least amount 
of injury. He could not agree with the opinion expressed that 
incision would afford any appreciable degree of securitv against 
septictemia, as compared with laceration. But, having had con- 
siderable experience in such cases, he did not recognise the inevit- 
able character of lajieration of coosiderable extent, and therefore 
he thought incisions would not be required. The tumour could 
be (and he had often done it) cut up by knife or scissors and 
removed piecemeal. Many proposals to this effect hod been 
made, and especially that of the spiral cut, whii-h he descrilied, 
whereby the tumour was, by cutting, made into a long strip. 
This plan he had used with some degree of success. 

Dr. Hktwood Smith replied to the observations of Dr. Murray 
and Dr. Wiltshire, that in his case it would have been im|>os- 



288 SPRINO BBTBOVEBSION FESSABT. 

aible to remove the tumour without injury to the periueum, as 
the tumour had already diatended and quite fiUed the Tagiuol 
cavity, and the vulval orifice was small ; and he judged that a 
clean cut, if properly adjusted, would heal better thau a torn 
wound, eveo if such had been brought together. 



SPRING PESSARIES. 

T)r. Bevbblbt Cole showed an instrument designed to 
meet the indications of a large class of cases of retrover- 
sion and SexioD, in which from exquisite sensibility, whether 
primary or secondary, the employment of ordinary pessaries 
is contraindicated or inadmissible. 

It consists of a common Hodge or Smith's pessary, the 
upper arm of which is shorter than the original instru- 
inent, and at the same time less curved, so as merely to 
adapt it to the curve of the floor of the vagina. 

To either lateral arm a segment of a watch spring, 
about one and half inch in length, is attached, these two 




supporting at their distal extremity a bar of vulcanite or 
celluloid — this latter being intended to occupy the fornix 
of the vagina and uterus posteriorly. The advantage of 
the pessary so constructed is that the uterus instead of rest- 
ing on & fixed bar is allowed to ride, so to speak, upon the 
spring, obviating the inconvenience of the older arrange- 
ment. A woman wearing tliia instrument finds great 
comfort. Whilst the womb is raised, or rather supported, 
when properly replaced, unlike other pesearies, in the act 



SPRING ANTEVEHSiON PESSARY 



239 



of defecation the bar of the instrument is paehed forward 
by the accumulated excrementitial material above, and the 
latter thus escapes without trouble, whereas, in the ordi- 
nary Hodge and other pessaries the bar is caught by the 
descending mass and depressed, and carried backwards so 
as to increase the difficulty attending this act. 

He also showed a " Spring Anteversion Pessary.'" Like 
the other, it is a common Hodge or Smith instrument to 
serve as a bed, and a spring attached to either lateral 



^ 



arm or bar. But in this these strings run in the oppo- 
site direction, in other words, run forwards. They, 
however, support a bai which is designed to exert pres- 
enre upon the fundus of the organ (like all others) through 
the anterior wall of the vagina and the bladder. AH who 
have had experience in the treatment of anteversion or 
flexions well know how sensitive the uterus is, and fre- 
quently irritability of the bladder is encountered, and how 
difficult it is to secure proper support through inatru- 
ments because of this sensitiveness. 

This pessary supports the womb and allows it to ride 
upon its upper bar, enabling the woman to engage in all 
usual occupations, even to dancing, withont complaining of 
the pressure, or experiencing any discomfort. 

He also showed an instrument, " Cole's Gas Cautery," 
designed for uterine, abdominal, and general surgical use. 
He considered it superior to the ordinary cautery iron, for 
it holds its heat when in contact with the tissues, and 
superior to " Pacquelin's Thermo-cautei-y," for it never fails 
to work, which so frequently occurs with the last-named 
instrument. 



240 THE LATE DE. 

It consists of an air reservoir gas attachment which can 
be adjusted like a drop light to any ordinary gas-burner ; 
a handle through which the gas and air are admitted, and 
the quantity of each regulnted by a stop-cock on each 
tnbe; a joint just above the handle enabling the operator 
in using the speculum to keep his hand out of the field of 
vision; and, finally, a series of platinum points of varioaa 
sizes and shapes, adapting it, as has been said, to every 
imaginable case of surgery. 

The great features of the instrument are its simplicity 
of construction, and the fact — that it never fails to work 
perfectly. 



THE LATE Dr. McCLINTOOK. 

The President desired, before proceeding to the chief 
bueinesa of the evening, to remind the Society of the 
great loss it, the profession, and the public had sus- 
tained since their last meeting, in the death of Dr. Mc- 
CUntock. He knew that the deceased had great respect 
for the Society, and that the Society in return greatly 
respected and loved him. It bad conferred upon him the 
distinction of Honorary Fellowship at the time of its 
foundation. He thought some Fellows might wish that 
more than ordinary notice should be taken of this sad 
and important event, and he would be glad to hear any 
motion on the subject. 

Dr. Bahnbb said — It is a sad privilege of a Senior of the 
Society to interrupt the ordinary business to recall to them 
that death has removed a fellow-worker from amongst U8. 
All will have heard with deep sorrow of the decease of Dr. 
Alfred McClintock, one of our first Honorary Fellows. 
The blow has been felt the more acutely because he was only 
lately amongst us presiding over the Obstetric Section of 
the International Medical Congress with all that grace 



THE LATE DB. UC OLINTOCK. 



241 



and ability for which he was distinguished. My friend- 
ship with him was of longer standing than that of most 
Fellows of the Society, It began when we were students 
together in Paris, I will not attempt to trace even briefly 
his career or his work. All are too freeh in our minds. I 
can only refer to the great qualities that stamped all he 
did. Candour, earnestness ia search for truth, absolute 
trust worthiness in observation and record, never shone 
more brightly than in Alfred McClintock. These qaalitios 
endow his work with lasting value. No one in the pre- 
sent or in the fnture need hesitate to accept a scientific 
statement made by him. After this highest of all praise 
it is no detraction to say that his was not one of those 
intellects, inventive and energetic, that compel to scien- 
tific progress. He weighed new ideas with a steady and 
cautious judgment. If we follow the old precept to say 
nothing of the dead but what is good unless it be true, 
the epitaph upon McClintock will not be a brief one. But 
it may be summed up in the simple phrase : All that can 
be said of him ta true, if good. 

Dr. Bamea then moved the resolution — "That the Obste- 
trical Society of London, having learned with deep sorrow 
the death of Dr. Alfred H. McClintock, one of its Honorary 
Fellows, hereby records its sense of the heavy loss which 
this Society, his profession, and science sustains by that 
event, and respectfully expresses its heartfelt sympathy 
with his widow and family in the still greater loss which 
falls upon them." 

Dr. Pkiestlet did not know when he entered the room 
that a motion was to be brought before the Society in 
reference to the death of Dr. McClintock, but if no one 
was appointed to second the motion so well proposed by 
Dr. Barnes, he craved the privilege of doing so. He 
might say that be had enjoyed a long acquaintance with 
Dr. McClintock, and greatly esteemed his friendship. He 
was a most earnest worker in the field which he had 
chosen as bis special province, and his lucid exposition of 
the subjects he studied and wrote upon indicated how 

TOt. xxiu. 16 



242 



THE LATE DB. KC CLINTOCK. 



careful he was as an otserverj and how independent he 
was as a thinker. His personal character was all that 
could endear him to hia many friends, and the eminence 
of his Bcientific reputation was indicated by his being 
chosen to preside at the Obstetric Section of the Inter- 
national Medical Congresa. Dr. Priestley had heard with 
profound concern of his untimely death, and ho believed 
his regret would be shared by friends and colleagues 
everywhere, for he was esteemed and admired cot only in 
England, Scotland and Ireland, but even in more distant 
rogiona, and he had never heard any opinion expressed 
about him except the highest and beat. 

Dr. Beverly Cole, — Mr. President, I rise with mixed 
emotiona of surprise and grief created by the announce- 
ment juat made through the motion ot Dr. Barnes of the 
death of our highly esteemed friend and brother, Dr. 
McClintock of Dublin. Apart from the personal acquaint- 
ance I had with him, and the obligations incurred 
through many politenesses extended to me whilst he was 
presiding over the deliberationa of the Obstetrical Section 
of the late " International Medical Congress ;" as an 
American I feel constrained to express, on behalf of my 
countrymen, colleagues, and professional brethren, the 
deep sorrow they will feel at the loss of one whom they 
knew more particularly through his earnest and con- 
scientious labours in the great field of science in which 
we are all engaged, whose character during life was so 
distinguished for profess ional zeal and integrity, and ■ 
whose name now goes down to posterity full of honour. 
Requiescat in Pace I 



ON SHORTNESS OF THE CORD AS A CAUSE OF 
OBSTRUCTION TO THE NATURAL PROGRESS 
OF LABOUR. 



By J. MATTHKwa Duncan, M.D., P.R.S. Ed. 

Obstecction owing to shortness of the cord stands, 
among the causes of difficult labour, in a category by 
itself. It ia not among those arising from a morbid con- 
dition of the powers of labour, though it may have infln- 
ence in perverting nterine action. It is not among tbose 
arising from a morbid condition of the genital passage, 
although the insertion of the cord high in the uterine 
wall forms a virtual increase of its shortness. Nor ia it 
among those arising from obstetrical morbid conditions of 
the foetus, as ordinarily described. It arises from the 
morbidly early establishment of a solidarity of, or union 
between, the foetus and the genital passage. The fcetus 
which should be propelled along the genital canal as 
freely as if it had no connection with it whatever more 
than what arises from contact, pressure, and friction, finds 
its progress arrested by a strong tether-Uke connection 
with the passage. As "soon as the cord is taut obstruc- 
tion commences, and abnormal mechanism of labour com- 
moncoE, for in a labour perfectly nataral the cord is at 

I no timo moro than taut, that is, tight without being 
Btretched or elongated. 
Cases belonging to tliis category have recently occurred 
in my practice, and I think it worth while to narrate 
Bome observations made in them and others similar, and 
some reflections on the subject. 
The cord may be absent, the placenta forming the 
anterior abdominal wall. When present, it may be very 
Bhort, measuring only a few inches, or it may be very 
long, measuring several feet. These extremes I need not 



244 



OSBTEDCTION OWINO TO 



the causation of difficalty in labour, and because the 
subject is frequently discussed in obstetric writings. 
Neither shall I here make any reference to conditions of 
disease or malformatiun of the cord, which may render it 
easily torn, but shall suppose the presence of a cord of 
ordinary strength. . 

Although there is no difficulty in measuring a cord 
from navel to placental insertion, and thus stating its 
length when not on the stretch, it is impossible to make 
a quite exact statement of the length of any cord while 
proving itself a cause of difficult labour. For when 
from shortness it is obstructiug the advance of the child, 
it is, after being t-aut, put on the stretch and may become 
considerably elongated. This stretching and elongation 
will vary according to the power applied, the time allowed, 
and according to the strength of the cord ; and its limit 
is the breaking of the cord. Bat) in addition to stretch- 
ing of the cord itself, some gain in length or distance 
from child to placenta is got by the drawing out of the 
two insertions, the navel and abdominal wall on the one 
hand, and the placenta and uterine wall on the other. 
Further, if the cord encircles the child in its coarse be- 
tween its two insertions, length may be gained by tight- 
ness of compression of the encircled parts, as of the 
neck ; and the same is true if the cord is, in a breech or 
footling case, morbidly shortened by passing between the 
thighs, the child riding on its cord, as it is called. 

In twenty-four experiments which I, along with Dr. 
Tumbull, made in the Edinburgh Royal Maternity Hos- 
pital, we found that the power of the cord to resist a 
breaking strain, its ultimate tenacity, was on an average 
eight and a quarter pounds, the weakest cord requiring 
iive and a half pounds, and the strongest fifteen pounds, 
to tear it across or break it. These experiments were 
made on lengths of cords attached to recently delivered 
placenta3, and the lengths so remaining attached were on 
an average nearly 17^ inches, the longest being 26 and 
the shortest 10 inches. The lengths were measured from 



SHORTNESS OF THE COED. 245 

the placenta to the ligature attaching the weight to 
the cord. In fifteen experiments the stretching of 12 
inches of cord was observed, and the elongation before \ 
breaking was nearly 2 inches. The greatest stretching j 
was 3 inches, and the least IJ inch. No fall of the 
weight nor jerk was allowed, and the weights were ap- 
plied and the experiment finished in abont a minute, JDst 
as the power of labour is applied in an actnal ease of 
short cord. 

In these experiments the cord after stretching did not 
break at the ligature connecting tho weights with it in 
any case, and in only one case at the placental insertion. 
A further series of experiments was made, which showed 
that at or near the placental insertion the cord was 
stronger than in the eonrse of its length, at least as far 
as near to the navel of the child.* 

The power of the cord to obstmct labour by its short- 
ness, whether that shortness is absolute or merely relative, 
is easily measured in its extreme limit, for it is just the 
strength of tho cord to withstand a breaking strain, or 
the weight which, duly applied, breaks it. ITiis weight 
does uot constitute a measure of the power to resist a 
jerk or weight falling from a height, as in precipitate 
birth while the mother is Btanding, nor of tho proof 
tenacity of the cord, that ie, its extensibility without 
injury of the tissues composing it, bnt it gives the ultimate 
tenacity or tensile strength. The power to resist a jerk 
or weight falling from a height has been well discussed 
and measured by Pfannkuch. No one has, so far as I 
know, made attempts to measure the proof tenacity, 

* " On the tftriDf^ of the cord " the vtloiible work of Pfonolciich sboiiM be 
conialtcd, in wLUb m&ii; references will bo founJ. (' Archiv fur Qjnasko- 
logie,' vii Band, 18TG, S. 88.) M; eipettmenti were completed befnn: the 
paper of Pfannkacb wti published, and I bave Dot had opportuoit; to n>ake 
more nith ■ view (o euct mmparuon with hii. The resolti of tho two wtf 
of fiperimenta differ contiderably and tbe eabject necdi further ■tiidj. Bape. 
«iall; do I want couliniiiLtion o( the itateraenl by Pfaunkucb thiil the curd 
mij' be itrotclied to half iti original length. 



246 



OBSTRUCTION OWING 1 



thougli many have discnssGd some of its conditions. But 
both of these measures are not of any importance in the 
inquiry now before ns. In the cases under consideration 
the cord is put on the stretch, and kept under moderate 
tension, till at last it is ruptured by the rapid yet not 
sudden or jerk-like application of the whole powers of 
labour. The propelling resnltant of all the powers of 
labour is of course greater than the ultimate tenacity or 
tensile strength of the cord when it is sufficient to break 
it asunder; and this breaking force comes thus to be a 
means of helping to fix the higher limit of the propelling 
power of labour. In caaes in which the cord is broken 
the propelling power is greater than the tensile strength 
of the cord. 

The mere measnrement of the length of the cord from 
its umbilical to its placental end is far from a sufficient 
statement of its shortness as a cause oE difficult labour ; 
for, as we shall immediately point out, a very long cord 
may, by rolling around the neck, be relatively a very 
short one and a cause of difficulty in labour. The cord, as 
a cause of difficulty, is to be measured as a length of rope 
botwuen two attachments, the foetal and placental ; and 
both of these attachments may be practically so varied aa 
to make the same length of cord a serious obstruction in 
one case and no obstruction at all in another. 

Tho cord aa a cause of difficulty will bo practically 
shorter according as its' placental insertion is higher in 
the uterine cavity ; fop when the child is passing through 
the vulva the distance between the fcetal attachment of 
the cord and tho lower parts of the uterine body is less 
than between the foetal attachment and the higher parts 
of the uterine body. 

The foetal attachment, or end for measnrement, must 
always be the umbilicus in cases of absolutely short cord, 
when its whole length is only a few inches. But abso- 
lutely very short cords are very rare, and shortness of the 
cord as a cause of obstruction is not very rare. A cord 
of any length may be made relatively short by being 



I 



SHOEINESS OF THE COED. 247 

rolled around the foetus. The ueck is the part moat fre- 
quently encircled, and it is this mode of abbreviation alone 
that I shall consider, for it is the most frequent source of 
difficulty from shortness, and, as already said, the short- 
ness is not absolute but relative. In this case the avail- 
able length is measured from the placental insertion, not 
to the umbilicus, but to the neck of the foetus. And it is 
to be remarked that the same length of cord measured 
from the neck will give the foetus less range than when 
measured from the umbilicus. In other words, the same 
length of cord considered as a cause of difficult labour is 
a greater obstacle when attached to the neck than when 
attached to the umbilicna. The attachment to the neck, 
or measurement from the neck, makes it practically shorter, 
because the neck is a distance of about two inches in 
advance of the nmbiiicua. The neck attachment will bring 
the same length of cord into a taut condition sooner than 
the umbilical attachment. The distance between the two 
attachments is not to be measured by the distance found 
when the foetus lies on its back extended, for in labour it 
has its body flexed and the two attachments approximated 
to each other. 

With the commencement of the premonitory stage of 
labour, or of the opening of the internal os uteri, there 
commences permanent shortening or retraction of the 
proper uterine wall or wall of the body of the nteras, and 
advance of the ovum, including the foetus, commences. 
During this stage the ovum and fcotus may not advance 
relatively to the pelvis, but it advances in the uterus till 
the cervix is expanded, and this expanded cervix the f<£tal 
head generally occupies before the commencement of the 
first stage, the external os uteri being as yet not dilated. 
No one has ever snspected shortness of the cord as a cause 
of difficulty in this premonitory stage ; yet it is quite con-- 
ceivable that it may be so, if it were extremely short. If 
there is no cord, as in certain monsters where the placenta 
forms the anterior abdominal wall, then morbid conditions, 
the result of the advance of the fcotus, will probably arise 



S4S 



aasmcwton awnm to 



vnn to this premoDitoiy stage of laboor or Etage before 
the Grst- We have Dot reliable accounts of very Bhort 
cords, and Crosse* discredits Davis's report of a cord two 
inches in length. But with a cord of even two or three 
inches in length I do not think disorder of roechaniem 
would arise, for the increase of distance between the two 
insertions probably does not exceed two inches in this 
stage; and the retraction of the body of the uterus ap- 
proximating the uterine insertion of the cord to its foetal 
insertion compensates nearly if not entirely for the slight 
advance of the fietal insertion in this stage. During all 
the progress of the fcctna through the genital canal the 
uterine insertion of the cord is also progressing, and in 
this premonitory stage we can be pretty sure that the 
advance of the uterine insertion compensates the advance 
of the ftetal insertion. 

If now we consider the progress of the first stage op 
tlie gradual opening up, on to full dilatation, of the 
external os uteri, we experience no hesitation in applying 
to it the remarks made on the mechanism of the premoni* 
tory stagG, 

To the second stage also similar statements apply, except 
in rarest degrees of shortness, so long as no part of the 
f<Dtus is bom ; and, so far as I know, theory is here not in 
disagreeraeut with esporience; bat when the head of the 
obild is born and bearing-down efforts assume the chief 
place in effecting further advance, the placenta being still 
attached, then advance of the fcetal end of the cord must be 
much greater than of the placental end, and the short cord 
will be put on the stretch. 

Stretching of the cord may supply sufficient length for 
the natural birth of the child. If it does not, then the 
cord may snap across, or the placental end may be freed 
by separation of the placenta, or the placental end may be, 
along with the uterus, pulled down, inversion taking place, 
or a kind of evolution of the fcetus may occur. 

When the cord is not strong enough to invert the uterus 
• 'On liiversto Uteri,' purt 2,p, ISJ. 



BHOETNESa OP THE COED, 249 

or separate the placenta, or to afford a fixed point for the 
process of evolution, then it may snap across, and this 
solution of the difBcult problem has been occasionally 
observed in practice. Indeed, as in CanoUe'a case, men- 
tioned by Crosse, inversion of the uterus and breaking of 
the cord may occur in the same case. 

We may be permitted to gaess that premature separa- 
tion of the placenta forms an occasional solution of the 
difficulty arising from shortness of the cord. This termi- 
nation has not been described, for it would not only not 
attract attention, unless in the very rare cases of excessive 
brevity, but, even if looked for, could not be, so far as I 
can see, shown to be the mechanism of delivery in any 
case, except, again, when the cord was extremely short and 
brought the placenta out with the foetus. It is not diffi- 
cult to comprehend this separation if the cord happens to 
be attached at or near to the upper edge of the placenta ; 
and it ia easy to imagine such separation permitting the 
easy birth of a living child without the occnrrenco of snch 
scarcely premature separation being noticed or suspected. 

Breaking of the cord is an easily understood termination 
of a case. A force of abont eight pounds is sufBcient to 
do this. Many interesting questions arise in connection 
with this rupture, which accumulated experience and obscr> 
vation can alone solve. Before the cord is broken the 
placenta may be partially separated, or the uterus partially 
or completely inverted, or evolution of the fostus may 
have been partly effected. I have not seen a case of the 
kind. Baudelocque relates a case of rupture of the cord in 
which it measured eight inches. 

Several cases of inversion of the uterus as a mode of 
termination of shortness of the cord are recorded. I have 
not seen one, and I shall satisfy myself with referring to 

I those mentioned in Crosse's great essay on inversion of 
the uterus, in connection with which Crosse eshibita great 
acutenesH in pointing out several of the explanations given 
in this paper. Baudelocque gives a case in which the 
cord measured seven inches. In Nownham'a case it 



I 



250 



OBBTSnCTION OWINO TO 



measured ten inches. In Smith's case six inches. Tliese are 
cases of absolute shortness. Baudelocque relates a case in 
which the shortness was relative, the cord encircling the 
neck twice, a leg three times, and an arm once. It is easy 
to suggest a mechanism of this inversion, for the traction on 
the cord, continuing in the absence of uterine contraotion, 
may partially invert the placental uterine site and may 
induce irregular or imperfect action of that part. The next, 
recurring, pain seizes the protuberant partial inversion and 
completes the morbid process. Without a careful study 
of the mechanism of inversion one might suppose it to be 
easily produced and likely to occur in this way, which it 
certainly is not. This is not the proper place to expatiate 
on the matter, and I shall only recall to mind the experi- 
ment of Keiller who found it impossible, in u case just dead 
from post-partum hBemorrhage at the full time, to produce 
inversion by seisring with his hand the placental site 
and pulling with all the power he could make available. 

The most common termination in cases of shortness of 
the cord is, no doubt, by the foetus performing an evolution 
which may be called spontaneous. This evolution I have 
several times watched when completely performed. It 
may be more or less perfectly completed, according to the 
degree of morbid shortening of the cord. Every practi- 
tioner meets with cases of cord encircling the neck and 
arresting the natural progress of the foetus after the 
shoulders are born. It is only the more marked oases, 
where obstruction is observed as soon as the child's bead 
is bom that strike him and attract attention. When the 
cord is extremely abbreviated, whether absolutely or 
relatively, so that birth by the process of evolution 
cannot occur, then, as in the cases referred to, the cord 
breaks or the uterus becomes inverted, or the placenta is 
separated. But cords of 10 inches and under are 
extremely rare; and it is probable that in most cases 
where the cord has even 10 inches from navel to placenta, 
birth by spontaneous evolution will occur. On the other 
hand, a cord of any length may be relatively shortened to 



8H0BTKB8B OF THE CORD. 



251 



B, morbid degree by encircling the fostal parts, and may 
cause obstruction. In a case which I watched lately, 
where obstruction was eufficioat to necessitate the evoluiion 
of the foitus, the cord measured 2;J^ inches. It twice 
encircled the neck of the child, and the distance between 
the neck and the placenta was 11 inches. If we allow 
2 inches as the distauRe between the neck and the 
umbiHcus, there was a shortness equal to 9 inches, 
measured as absolute length from navel to placenta. In 
a closely simitar case I measured the cord 27^ inches in 
length, but I did not get a good measurement from the 
neck. In this case obstruction did not occur till after 
the head and shoulders were bom. 

In cases of great absolute shortness the process of 
evolution will not be completed it the cord is artificially 
divided by the accoucheur; and in cases of relative 
shortness it will generally not be even commenced if the 
usual good practice in such cases is adopted. This 
practice consists in feeling for the cord in the hollow of 
the neck as soon as the head is bom, seizing it, and 
pulling to get a slack sutHcient to let it be passed over 
the head, and thus to remove the encircling. When 
sufficient slack cannot be easily got to allow the cord to 
be passed over the head, there may yet be enough to 
allow the shoulders to pass through the loop, and thus 
obstruction by relative shortness may bo obviated. The 
process of evolution in a case of relative shortness is seen 
when neither of these plans has been adopted, or when 
the progress of the child under powerful labour is so rapid 
as to give no time for the treatment. 

Daring the evolution the fcotns rotates eo as to bring 
its anterior surface to look forwards. This rotation is in 
a direction such as to partially undo the encircling and 
thus diminish the strain on the cord, and the strain on the 
cord is the canse which produces it. This part of the 
evolution may be artificially performed in order to aid 
delivery. 

The erolntion itself has analogy with other evolutions 



252 



OBSTEUCTIOS OWINO TO 



observed in morbid labonpB. As, for example, in the 
spontaneous evolution of Douglas, one or other pubic bone 
forms a fixed point for the revolving foetus, so here the 
fojtal end of the available length of cord, whether it be 
navel or neck, forms the fixed point. As in the sponta- 
neous evolution of Douglas the body revolves around the 
pubic bone, so here it revolves aifcund the fretal end of the 
cord. In the spontaneous evolution of Douglas the process 
is performed partly in the abdominal and partly in the 
true pelvis, so here the process is perfonaed partly 
outside the mother's body partly in the true pelvis. 

The cord is first made taut, and as it becomes stretched 
it lies in close apposition to the urethra, forming the 
shortest possible lino between its placental and fcetal ends. 
The fcetal end is kept as near as may be to the orifice of 
the urethra, and while it is so the unborn parts of the 
foetal body are forced down through the lower part of the 
genital passage, the upper parts of the foetal body being 
pressed towards the mens veneris. 
^ The following conclusions may be stated : 

1. A cord of any length may be rendered morbidly short 
by being rolled around the parts of the foetus. 

2. A cord morbidly short in a lesser degree does not 
prevent the progress of labour, the child being born by a 
process of evolution, more or less complete and difficult 
in proportion to the shortness of the cord. 

3. A cord morbidly short in a higher degree arrests the 
progress of the labour until the placenta is separated, the 
cord torn asunder (or cut), or the uterus inverted, 

4. No nearly exact statement can be made of the 
number of inches constituting the leaser or the higher 
degree of morbid shortening of the cord, because of the 
varied amount of stretching of the cord, and because of 
the varied insertion of the ends of the part to be measured. 

5. A cord of the lesser degree of shortness probably 
varies from 12 to 14 inches when stretched and elongated, 
if measured to the neck of the child, and from 10 to 12 
inches when stretched, if measured to the umbilicus. 



Jte 



SeORTNESS OF THE CORD. 200 

6. A cord of the biglier degree of shortness measares 
probably under 10 inches when on the greatest stretch. 

Dr. J. Bbaxtom Hiceb thought thut it was the general plan 
with obstetricians, in the case of a. veij short funis, either 
directljf short or shortened by being coiled round the part of the 
child, if it iinpeded the exit of the child or ^trained it so that its 
cireuiation was impeded, to divide it as best we might, without 
attempting to tie either eud, as the ftetal portion can be easily 
seized while the child is being expelled or drawn down. Dr. 
Hioks described a. remarkable case he hod seen, as follows : 



TWINS: SHORT FUNIS IN BOTH. 



By J. Beaston Hicks, M.D. Lond., F.B.S.^ 

OBBin&IQ rSTBICtAK AT- OCl'S nOaCllAl, STO. 

(Id Canialtatiou wicb Dr. Qoas.) 

Mrs. — , Union Street, Trinity Square. In her sup- 
posed eighth month of pregnancy — very large and cumber- 
some — was dolirered of her first fcotua at U a.m. Liquor 
amnii very copious, whereby the presentation was first 
the arm, but afterwards the feet came down. The funis 
was exceedingly short, so that it could be scarcely tied 
and divided. 

The second amnial sac waG very fuU and broke shortly 
after birth of first child. Upon this the uterus became 
qoiet, and so continued till 9 p.m., when, slight action 
beginning, the presentation was found to be the feet. I 
gently drew down till the breech was at oh uteri. I left, 
recommending a dose of secale if the uterus remained 
inactive; in about three- qaartera of an hour it was given, 
and the pains came on, pushing dowii the breech to the 
vnlva, where it remained for aome time, I again was sent 
for, and found no obstruction below, i.e. in the pelvic 
cavity, therefore the detention was higher. The patient 
waa placed under chloroform, and I passed my hand up- 
wards. I found the child ccdematous, and to reduce its 



254 OBSTRnCTION OWING TO 

size, and also to assist in the traction, I hooked the crochet 
into its abdomen. Some flaid escaped, which allowed 
more freedom of action. I now could feel the funis very 
tense, the umbilicus being stretched up. It was above 
the symphysis pubis. 

I determined to divide the funis, and having inmy bag the 
osteotome of the late Sir James Simpson, I guided it up 
between two fingers of one hand, and divided it. Upon 
using fair traction the body came down. The funis waa 
about four inches long altogether, iThe placenta (single) 
was not spontaneously expelled. I have no note as to its 
position, but am under the impression it was at front of 
uterus. However, I had an opportunity of observing 
a rare cause for concealed post-part am hEemorrhage, 
first noticed by Dr. Blundell. A bag of the membranes 
protruded fi'om the os, the uterus being in fair action. 
On rupturing this a large rush of blood took place. I 
instantly pas>aed my hand within, and peeling off the 
placenta so much as was adherent, removed it in the 
usual way, whereupon the bleeding ceased. 



A 



Dr. B&BNKs observed that several points in the paper bad 
arrested his attention. He was rather surprised to hear Dr. 
Duncan describes the cord aa aometmea springing from the edge 
of the placenta farthest from the os uteri internum. Levret had 
iong ago pointed out that the cord, if it sprang from an edge, 
alwitjfl eprang from that nearest to the os. He had himself in 
his researches on placenta pnevia constantly verified this con- 
elusion. It was a thing easily determined. He heheved there 
was a physiological reason for it. Without, however, absolutely 
denying that the cord might spring from the farthest edge, he 
would put it interrt^atively : Where is the evidence that it does P 
The remarks upon the encircling of the neck of the cord aa a 
cause of spontaneous evolution were interesting. He would 
submit, as a means of lessening the tension of the cord artificial^ 
shortened, the method of compressin); the uterus downwards 
during the second stage. This would give an inch or more by 
approximating the placental attachment to the festal end of the 
cord. And instead of losing time, not always at disposal, in slip. 
ping the loop over the child's head, or opening the loop to let 
the shoulders jiass through, a mancnuvre not always possible, he 
had found it better to cut the cord at once. This entailed no 



SBOKTNESS OF THR CORD. 255 

danger to mother or child, and permitted the rapid extrication 
of the child from the danger of strangling. 

I>r. HiCKiNBOTHAJn reaia.rked upon the dia^osie of cases of 
obstructed labour from short funis, and related a case he had 
seen the previous day, in which the condition was recognised by 
the fact that with a roomy pelvis, sufficient paina, and a foetal 
head easily movable in the intervale, yet no progress was made. 
He advocated immediate forceps delivery and the prompt 
division of the cord. 

Br. Gebvib called attention to the advisability in cases in 
which the forceps were used, of ascertaining as soon as practi- 
table whether or no the cord encircled the neck. He ha!d met 
with cases in which, necessarily, the forceps were put on before 
the head was low enough for this point to be noted, and in which 
the cord around the neck proved both an obstatle to delivery and 
a source of danger to the child. 

Dr. Wymm Williaks said he rose to point out a danger, not 
alluded to by the author of the paper, whicnoccasionally happened 
from the shortening of the umbilical cord. The danger, however, 
was not to the mother but to the child. He alluded to the rupture 
of the cord at its jnnetion with the child. He knew of two cases, 
one in his own practice, where such an incident occurred. Just 
as he entered the room the child was violently expelled, breaking 
the cord at its insertion into the abdomen of the child, the 
vessels being drawn almost within the abdomen ; fortunately he 
had a tenaculum in his pocket, and succediug in hooking out the 
vessels and placing a ligature upon them. 

Dr. BoBGRTsoM desired to record a case of rupture of the 
cord which occurred in his practice some time a^o. The patient 
was confined of her third clmd, which was born five minutes before 
his arrival. He found the cord of averf^e length and thickness, 
but severed about five or six inches from the umbilicus. Htemor- 
rhage from the cord had ceased and the child did well. 

Dr. MuBBAV wished to remark on what had fallen from Dr. 
Barnes touching the pressing of the fundus uteri from above, 
and BO assisting delivery. He remembered a consultation case, 
where after the use of the forceps pressure was made, and In so 
doing the rotundity of the ulorus gradually got less and less, 
when, on feeling for the placenta, the first stage of inversion 
of the uterus was detected; the placenta was easily removed, 
and the fundus uteri re-adjusted. 

Dr. BsniiTDN said that it had been stated, as a sign of short- 
ness of the cord, that, if the placental attachment is at the usual 
phtce, with every pain there is a depression of the fundus uteri 
to be seen and felt, such depression gradually disappearing as 
the pain goes off, and the rounded form being restored in the 
interval of rest. 

Dr. Haxgs inquired whether ia the exptirioii^nts made hy Dr. 



256 OBSTRDCTION OWING TO SHOETSKMa OP THE COED. 

Pimcan to test the tensile etrength of the cord, anj note had 
beea tab.en of the thickneBs, Dumber, and condition of the 
vessels of the different cords F In hia own practice he had never 
met with inversion of the uterus ae the result of pulling upon 
the cord, or attributable to an unusual shortening of the cord. 
Dr. Duncan had also remarked that he had never met with a, 
case of inversion with short cord. Breaking of the cord from 
pulling was very common. Dr. Hayes therefore could not help 
thinking that where inversion had occurred with an abnormally 
short cord, some other factor — perhaps thickness, condition of 
TesBelH^beaides mere shortness, had bad something to do with 
the production of the accident. 

Dr. Ems thought that, in some instances where the cord was 
twisted several times round the neck thus delaying delivery and 
forceps were employed, as soon aa traction was exerted the undne 
strain upon the cord interfered with the fcetal circulation, ^ving 
rise to convulsive movements on the part of the fcetua. Prolapse of 
the cord by the side of the head would be still more likely to 
cause such a result. He had witnessed such cases, the child 
being apparently stillborn and resuscitated with difficulty if the 
delivery were delayed. 

The Pebsident found the valued criticisms on his paper 
had reference chiefly to practice, and to this he had no posi- 
tive objection; but the paper was written with a view mainly 
to the description of mechanism. He thought Dr. Hayes 
would find that variations of thickness of the cord made little 
variation in its tensile strength ; the matter was one that could 
easily be settled by experiment and in no other way. He hoped 
that the rare case of Dr. Murray and the unique and moat 
valuable case of Dr. Braston Hicks would be well recorded in 
the reports of their speeches. With Dr. Barnes he concurred 
in supposing that the cord was, in battledore placenta, at least 
generally, inserted in the lower border ; but it was only sup- 
position, and he knew no physiological reason why it should not 
be inserted in the upper border. 



I 




DECEMBER 7th, 1881. 

J. Matthews Duncas, M.D., F.B.S. Ed., President, in the 
GhaiT. 

Present — 66 Fellows and 8 visitors. 

Books were presented by Dr. Pancourt Barnes, Mr. 
George Eastea, Dr. W. T. Luak, Prof. F. Macari, Drs. A. 
Meadows and A. J. Venn, the Royal Medical and Chi- 
rargioal Society, the Clinical Society, the Edinburgh 
Obstetrical Society, and the Editor of the ' Beitrage zur 
Geburtshiilfe ' (* Festgabe,' za Prof. Cred^). 

F. Parley Taylor (of Prince Edward Island) was declared 
admitted a Fellow of the Society, and Dr. C. S. De Lacy 
Lacy and Dr. Arthur Perigal were admitted Fellows. 

The following were proposed for election: — George 
John Eady, M.R.C.P.Ed. (Caterham) ; Joseph Farrar, 
L.R.C.P. Ed. (Morecambe) ; Francis Boynton Lee, 
F.R.C.P. Ed. (Heckmondwike) ; John Edward Norman, 
M.R.C.S. (Esh, Durham) ; William Peacey, M.B. ; John 
Phillips, B.A., M.B. ; Amand J. M. Hoiith, M.R.C.S. ; 
William Francis Sheard, L.R.C.P. Ed. (Ridney) : Stephen 
Maberly Smith, M.R.C.S. (Geelong, Melbourne) ; and 
George Snell, M.R.C.S. (Berbice). 

Dr. John Brnnton, Dr. Easton, and Mr. G. R. Ord, 
were nominated auditors of the year's accounts. 
VOL. IVIII, 17 



OVAEIAH TDMOUB. 



I 



I 



Mr. Knotvelzt Thohnton showed a portion of an oT&rian 
tumonr with the Fallopian tube adherent by its fimbriated 
extremity to the opposite ovary, which woe so completely 
grasped that it had partly atrophied. 

He said : This remarkable specimen is part of a tnmour 
of the right OTary, with the right Fallopian tube, into the 
fimbriated extremity of which the left ovary has passed 
and become fixed by iuflammatory adhesion of the fimbrise 
all round it. It demonstrates perfectly an occurrence 
which I have been led to suspect by a series of cases in 
which both ovaries have been found to be involved in one 
tumour, the respective tubes and ligaments forming two 
distinct pedicles. 

I have now operated on several cases of this kind, and 
in the first case, from a dissection of the tumour, was led 
to suspect that the double pedicle arose from the condition 
which the present specimen demonstrates. The last case 
of the kind that I operated upon showed the condition very 
fairly, as the secondarily involved ovary had not at the time 
of operation become included in the mass, but was still dis- 
tinctly recognisable. lu this preparation the two tubes 
are quite distinct, but the left tube, at its free extremity, 
has, together with the left ovary, been partly swallowed 
by the right tube, the fimbrise of the latter having then 
cloBoly adhered all round, and the ovary is now in a partly 
cystic and partly atrophic condition. 

It appears to me that the probable explanation of the 
condition in this case is as follows : — The right ovary, 
becoming cystic, stretched and elongated its tube ; the 
tube, by the direction of the growth of the cyst, was car- 
ried into contact with the opposite ovary, and its fimbriss 
falling over this left ovary, just as they would in health 
over their own ovary, became adherent, through some 
irritation or local peritonitis, common enough in the 



TKANSLUCENT BAC. 259 

growth of every pelvic tumour. If the iuflammatory 
action be extensive, the grasped ovary may atrophy and 
disappear as the newly- formed tissue contracts round it, 
or it may become involved iu the mass of a rapidly- 
growing tumour and bo disappear. I feel certain that I 
have seen specimens of both conditions. 

The patient from whom this tumour was removed was 
forty-three years old and single. She had becu quite 
regular up to her fortieth birthday, and was menstruating 
regularly at that date, when she caught cold and the period 
stopped suddenly, and she never menstruated again. She 
had not at that time noticed any increase of size, but had 
been troubled with a beating in the'right iliac region, and 
this was accentuated at the time the menstruation was 
checked, and she bad some slight pelvic pain, but never 
anything sufficient to lay her up at all. This history 
coincides well with the condition found at the time of 
operation, for there had evidently been no extensive 
inflammation in the pelvis. 



I 



TBANSLUOENT SAC. 

Dr. Hebuan showed microscopic preparations from a 
specimen he had exhibited at the October meeting. (The 
specimen was a, translucent sac containing clear fluid, and 
a small solid body attached to its wall.) Dr. Herman had 
submitted the specimen to his colleague, Mr. McCarthy, 
who had been good enough to examine it microscopically, 
and to allow the preparations to be exhibited. One slide 
showed the membranous wall of the sac. It consisted of 
fine rudimentary fibrous tissue, and was sheathed with 
epithelial colls, such as are seen in unquestionable amnion. 
The other showed a section of the solid body. This 
body was about a line in length and three quarters of a 



I 



CONJOIMED TWINS. 261 

She baa alxvaya previously had good confinements, but 
felt ill the whole of this pregnancy, which dated from 
April 14th, 1881. When taken in labour, prematurely, the 
midwife was sent for. The first stage lasted three hours. 
The face presented in the third position, the forehead 
being diret,ted to the right sacro-iliac synchondrosis. 
The second stage lasted six hours, and would have gone 
on indefinitely had not the midwife sent for assistance. 




Forceps were applied, and delivery took place in the 
following order : — The first head being born, a monster 
was diagnosed, and the other head felt over the pubes.* 
Traction was made, and the shoulders, arms, and trunk of 
No. 1 were brought down j these were followed by the 
four feet simnltaneonsly, and the rest of No. 2 as a foot- 
■ See iketch. 



362 FIEBOUA OP THE UTEBUB. 

ling, the pubic bones forming an axis round whioh e^oln- 
tioQ took place. 

The children (both female) were stillborn, measured 
fonrteen inches, and weighed five pounds. The mother 
made a good recorery. There was a single placenta and 
but one cord. 

It would seem something- more than a coincidence that 
the last seven caeea of conjoined twins were all girls. 

Dr. WiLTSHiEE inquired if the relations of the foetal envelopes 
threw any light on the question whether a. double-yelked ovum 
had existed in this case ? 



FIBROMA OF THE UTERUS. 

Db. Hktwood Smith exhibited a tnmonr removed from 
a patient, set. 55, married thirty-one years, whose only 
pregnancy resulted in abortion twonty-niue years ago. 
Sir James Simpson had seen her more than twenty years 
previously, and had diagnosed fibrous tumour of the 
ateruB. Recently a cyst had developed, and Dr. Heywood 
Smith diagnosed ovarian cyst, and also came to the con- 
clusion that the solid tumour was a fibroid of the ovary. 
At the operation it was found that the cyst was an off- 
shoot from the solid tumour, and the whole tumonr was 
removed, the pedicle being very short, close to the right 
comu of the uterus, aud so hard that the needle was 
passed with considerable difficulty. The patient recovered. 
Before the operation the patient had suffered from 
several severe floodings, and since the operation there 
had been considerable metrorrhagia. Dr. Gabbett, the 
pathologist at the Hospital for Women had made a careful 
examination of the tumour and found it to consist wholly 
of dense fibrous tissue, with several rounded tuberosities 
and thin-walled cysts on its surface. There was no trace 



PALLOPIAH-TUBI PEIONAKCY. 263 

of the stroma of the ovary, and nothing to distingniah it 
from a fibroma of the uterus. 

Mr. Alban Doban did not understand why pathologista 
were so reluctant to recognise fibro-myoma as possible in the 
ovary. The ovarian stroma, around the follicles, the vestigial 
epithelial elements, and the thick-walled vessels contained an 
abundance of ceils with long nuclei, closely resembling the plain 
muscular fibre of uterine tissue and of fibro-myomatous tumours. 
The ovarian ligament was normally pure non-striated muscular 
tissue. Mr. Doran had seen several examples of largo and of 
small fibro-myomata which absolutely occupied the seat of the 
ovary, and did not extend beyond the limits of that organ. The 
distinctness of these tumours from the uterus waa particularly 
evident, not only through the position of the Fallopian tube, but 
also owing to the great hypertrophy of the ovarian ligament, 
which increased the distance of the diseased ovary from the 
uterus. This law of hypertrophy of appendages of oi^ns 
invaded by tumour apphed to the hydatid of Morgagni in most 
forms of ovarian and tubal disease ; m one case of multilocular 
tumour of the ovary, removed the day before by Mr. Thornton, 
the hydatid measured four inches in length, its pedicle being 
enormously elongated. All the ovarian fibro-myomata referred 
to contained cysts. 



I 

^^L hours. The abdc 
^M blood. 



FALLOPIAN-TtJBE PREGNANCY. 

Thz Pbbsidbnt shovred a right Fallopian -tube preg- 
nancy. The laceration is very long, measuring one and a 
half inch. The patient consulted Mrs, Falconer, at the 
Stirling Infirmary, thinking herself four months preg- 
nant; the fcctas is of about five weeks only. She com- 
plained of weakness and pain in belly. She had 
syphilitic psoriasis, was ansemic, and had been losing 
blood repeatedly per rectum. She died in thirty-six 
hours. The abdomen contained large masses of clotted 
blood. 



EPITHELIOMA OF CEEVIX'WITH PREGNANCY. 



Dr. Edis asked for an expressioii of opinion in the 
following case : — A patient, Eet. 29, married two years and 
nine months, mother of one child, eighteen months old, 
which she suckled for twelve months, presented herself iu 
the out-patient department of the Middlesex Hospital in 
November complaining of pain in the back, sanguineous 
discharge, alternating with a thick, yellow, offensive dis- 
charge, and other symptoms. On examination she was 
found to be about six months pregnant ; the whole of the 
cervix uteri, and the posterior wall of the vagina, down 
to within one inch and a half of the perineum, was 
affected with epithelioma. The cervix was dense, nodu- 
lated, rough, and friable, but did not bleed as readily 
upon touch as usually noticed. She was admitted under 
the care of Mr. Hy. Morris with a view to operation. On 
careful examination the posterior wall of the vagina was 
found to be too much involved to admit of the whole of 
the diseased mass being removed by the Porro-Freund 
operation. The question to be decided therefore was 
whether premature labour should be induced now, so as to 
lessen the risk of injury to the cervix during parturition — 
the child being to all intents and purposes now viable— 
or whether the pregnancy should be allowed to go on 
nearly, or quite, to full term, and then Ctesarian section 
be performed, so as to give the child a chance of living, 
without increasing appreciably the maternal risks ? 

Dr. Wiltshire felt it difficult to express an opinion without 
seeing the case ; but he thought that if the disease had extended 
down the posterior vaginal wall nearly as far as the periueuni, 
the valuable operation of Porro would fail in completely re- 
moving the disease. He mentioned a case of excessively dense 
cancer of the cervix uteri whioh he had seen some years ago in 
consultation, and for which he pei-formed Ceesariau section. 
Here Porro's operation would have been admissible had it been 
then in vogue, as the disease was chiefly in the ecrvis. 



EPITHELIOHA OP CEBVIX WITH PREGNANCY- 



265 



Dr. Herman said tba,t published cases of pregnancy with 
cancer of the cervia uteri showed that the difficulty o£ delivery- 
depended more itpoa the consistence of the growth than upon its 
extent. Cases had been reported in which, although the whole 
circumference of the cervix uteri and upper part of vagina was 
cancerous, yet living children bad been born after quick and 
easy laboui-a, and, conversely, a cancer of small extent might, if 
ve^ bard, cause great obstruction to delivery. 

Dr. Peiestlet said he thought the remarks of Dr. Herman 
really went to the root of the question. The propriety of any pro- 
cedure must be determined by the extent of the morbid growth 
and by its consistence. It was well known that some of the forms 
of epithelioma were so soft and friable that they broke down and 
almost melted away in attempts to remove them. A. growth of 
such a soft character might occupy a considerable extent of 
surface and yet readily give way during the progress of labour 
at the full time. He did not think the case a suitable one for 
Porro's operation now, as at the sixth month of pregnancy 
the fcetus would not be viable, and the mother's life could 
scarcely be prolonged by such operation. Seeing that the 
woman's life could under no circumstances be much prolonged, 
suffering as she was from malignant or pseudo-malignant 
disease, he thought the preservation of the child's life should be 
the chief object aimed at, and he should be disposed to let the 
woman go tSe full time, or nearly so, and then be guided by the 
amount of obstruction in the va^na in judging whether it was 
better to attempt to deliver by the natural passages or to 
perform Ctesarian section. 



NOSJIAL AND PATHOLOOICAL ANATOICY 



I 
I 



ON THE NOBMAL AND PATHOLOGICAL ANA. 
TOMT or THE GANSLION OBRVICALE UTEKI. 



By N. W. Jastrebopp, 



L 



ACiCE^T OF St. PEIEEBBOnO. 

{Commnnicsted bj the PBaaiBum.) 

The pathology of the nervoaa system of the female 
genital organs has as jet been made the subject of almost 
no Bcientifio work. But we know well enough that it 
playa a great part in the diseases of these organs from 
researches on the pathological changes of the nervous 
system of other diseased organs. For instance, Jwanow- 
sky* has shown parenchymatous changes in the nerve cen- 
tres of the heart in spotted typhus, whereby he explains the 
paralysis of the organ in the early stage. Putjatinf also 
found in chronic diseases of the heart interstitial morbid 
processes in its nervons ganglia, with consequent fatty 
degeneration and pigment infiltration, which had as a con- 
Beqaenoe functional disturbance or even paralysis of the 
organ. Bosonow, Zotltmann, Eichorst, and WassilieffjJ 
showed further that, after cutting through the vagus, not 
only functional disturbance of the organ came on, but 
that also anatomical changes took place in its muscular 
structures. 

From this short review it is to be remarked that like- 
wise pathological processes in the nerves of the genital 
organs may induce not only functional disturbances in 

• Jwanowslij, " Zor Path. Anat. des Flecktyphna,' 
path, Hlst^l. ti. klinische Mod. Herausgegi^ben,' van 
(Rauian). 

t Patjatjn, ' Ueber dio path. Verenderangen in dan luatom, Ganglien- 
oentrcii des Hertens bei chron. ErkraokoiigeD dMielben.' Diaaert, 1677 
(TtaiBiui}. 

X WaBsiljoS', ' Ueber die tropliiscbe Wirlinng dea Ta)^iasuf den Hcrzmiukel.' 
DiHert. 1870 (Rnuiao). 



OP THE 6ANQLI0N CBRTICALB CTEEI. 267 

them, bat also anatomioal changes, But that the patho- 
logical department is so little cleared up is well explained 
by the great bSanke which atill exist in the ordinary ana- 
tomy o£ this part of the nervous Byetem. Having been 
asked by Professor Slawjansky to occupy myself with the 
anatomy of the nervous system of the female genital 
organs, I chose for my present work the cervical ganglion 
of the uterus in its normal and pathological conditions, and 
here publish the results I have arrived at. 

Having regard to the literature of the subject, we fiud 
it given np to 1867 in Frankenhsenser's comprehensive 
work, ' Die Nerven der Gebarmotter.' But Lee's views 
appear to us to be not fairly stated by Frankenhsensei-. 
For instance, he represents Lee as describing at the neck 
of the womb one great, and several small ganglia, from 
which nerves proceed into it. When we compare this 
statement with the original, we find that Lee describes 
one great ganglion at the neck of the womb, from which 
nerves run into the organ, and he describes the smaller 
ganglia as placed in the middle of the vagina, and from 
them nerves arise and proceed into the vaginal walls aiid 
subdivide there. Although these ganglia are connected 
with the utero. cervical ganglion of Lee, or the cervical 
ganglion of Fran ken heeuaer, they have no direct connec- 
tion with the nerves of the uterus. The ganglion itself 
he describes as a white, solid, undivided mass of tisane of 
irregular triangular form, with projections at those places 
where nerves either enter or depart, and it supplies the 
posterior border of the lateral part of the vaginal laquear, 
the side wall of Douglas's space, and the anterior part of 
the rectum. In its mass are found oue, two, or three 
openings for vessels. The ganglionic mass surrounding 
these openings is, however, eo great that the ganglion has 
never a net- like appearance. 

On the histological structure of the ganglion Frankea- 
faesuser remarks : "The ganglion consists of ganglionic 
cells placed close to one another, which are separated by 
nerves." Theso words contain a contradictioa regard- 



J 



268 SORMAL AND PATHOLOOIOAi AtJATOMT 

ing the Btrncture of the maas of the cervical gftngUon, (or 
at one place he says, founding on macroscopic observation, 
that the mass is indivisible, and adds further on, founding 
on microscopical observation, that it consists of ganglia 
and nerves. Again, he describes the mass in its entirety 
as a ganglion, which is in discordance with the statement 
that it consists of ganglia and nerves, and is therefore a 
complex structure. These contradictions are inexplicable. 
After Frankenhaauser, we find in literature very little 
that has reference to the ganglion in the neighbourhood 
of the neck of the womb, or of the vagina, and no 
special researches, 

Henle,* describing the utero-vagiual plexus, says that 
larger and smaller ganglia are found at the neck of the 
womb and upper part of vagina, in greater number at the 
sides and iu less number on the anterior and posterior 
surfaces. 

Sappeyt only remarks that ganglia are observed in the 
conrse of the uterine nerves, which have already been 
described by Remak in 1840, by Polle and Koch in 1865^ 
and by Frankenhreuser in 1867. 

If we lay aside particulars, we find the statements of 
different authors regarding these ganglia divided into two 
groups r 

1. Authors who recognise a ganglion at the side of the 
neck of the womb or of the vagina — Walter, Lee, and 
Frank enh seu ser . 

2. Authors who, instead of a ganglion, recognise an 
extensive nervous plexus with greater and larger ganglia, 
and who admit no ganglion at the side of the cervix uteri 
or of the vagina — Tiedemann, Moreau, Remak, Jobert 
de Lamballe, Snow-Beck, Kilian, Boulard, Herschfeld, 
Komer, Luschka, Polle, Henle, and Sappey. 

It has now to be asked — How are these contradictions 
to be explained ? This ia partly done by the difficulty of 
making preparations of the sympathetic nervous system 
* ' Hnndbnoli der NBTvonlelire dea Menschea.* 1S71| ■' S81- 
t 'Traits d'AnntomiB d«Boriplive,* tome iii. Puis, 1877. 




OF THE OASOLIOS CEHVICALE CTEGI. 



269 



f'generalj and quite particularly of the nerves of the 
genital organs, which are so firm and so close one to 
another. On the other hand, the mode of preparation is 
of importance, and it differs in some respects from that 
generally need. 

It is, however, in the highest degree interesting to 
settle the questions : 1. Is there a ganglion at the neck 
of the womb or in the vagina? 2. Is thia structure 
simple or complex ?, that is, does it consist macroBcopically 
and microscopically of separate ganglia ? 

We have set ourselves to solve these questions by 
anatomical research. A.s material we used thirty bodies 
of different ages, but moat of childhood. Here I give 
briefly the results arrived at, without stating fully the 
methods of preparation and of investigation. 

By the ordinary method of preparation we find at the 
union of the twigs from the hypogastric plexus with the 
twigs from the sacral nerves many small ganglionic 
swellings of different forms. By comparing diiferent 
preparations, the difference of form of these swellings and 
in their number was evident in every preparation. As 
we could not admit the possibility of so great differences 
in number and form of the ganglia, we were inclined to 
refer it to the method of preparation, and sought by that 
means to explain the above-named variations of statements 
of authors. 

Making preparations with pyroligneous acid or common 
vinegar, after they had lain in spirit, we found at the 
anion of the hypogastric plexus with the twigs of the 
sacral nerves a solid mass which resembled a nerve 
ganglion, and which was eigbt millimetres long and three 
broad ; that is, we had the so-called ganglion of the cervix 
uteri of Frankenhieuser. After preparing it with osmic 
roscopical examination, to consist 
The interstices between the 
ganglia were filled up by loose cellular tissue, fat, and 
vessels of different sizes, and nerve branches. Now, by 
a nerve ganglion wo understand a group of nerve-cells 



acid, we found it, by mi 
of many small gangli 




XOKXAb ASV f linOMMOL MuaoT 



I 




which is sBmonded bj pengngfiooie eoamBCtirm-tiammt 
aad is dividfld faf nam Ebvn and Iaj«& of cndo- 
gmn^MBDC eonneetrra tnoe. So far as eaneena Ae 
atmetnra vt peri- wad endngMig<ionM eonaectiTe tiw^ 
we A^ree, (oondmg mi our own iorvsiigttiaa, villi Ax^ 
Kej, and Betzins. Making £iaectiona froB tbe bodios 
of newlf-bom childreii, after treating with aeida in the 
frfsh oondition, that is, wilhoot patting them in spirit* wa 
coold nnder Wats', with additioa of spirit, coDTiiwe <mt* 
telrea ereo macrosoopically, or with the help of a Bmcke 
lens, that the cerrical ganglion of FivnkoiluBaser omnslad 
of manj ganglia, which formed two groups, ^te pos- 
terior-inferior groop is at the point of onion of the iimiitl 
nerre twigs with the twigs of the hypogastric plena ; 
the npper anterior gronp at the point of nnion dt aone 
sacral nerve twigs, which proceed oatwards and forwards 
Erom the first group, with the anterior twigs of the hypo. 
gastric plexus and with twigs which come from the 
ganglia of the first groap. From the first group proceed 
branches to the rectum, to the vagina, and to form onion 
with the second group ; and, lastly, many proceed 
upwards between the layers of the broad ligament. From, 
the second group go nerves to the uterus, and some of 
these by the side of the organ to the Fallopian tube, 
giring in their course twigs to the anterior and posterior 
snrfaces of the uterus j this group also sends twigs to 
the oreter, the bladder, and partially to the vagina. 
Thus, the first group may be called ganglia recto-vesicalia, 
tbe second ganglia utero-vesicalia. The connectmg twigs 
of the groups are about two millimetres long. 

On the twigs which go from these gronps to the 
rectum, vagina, and bl&dder, we meet with no ganglia, 
ao that they are quite isolated, lying above the vaginal 
Uquear, and giving as a whole the appearance of the 
BoUd cervical ganglion of PrankenhBenser, 

The position of the smail ganglia which constitute the 
mass of the Fraukeohaauser ganglion varies much in 
partioulara. Sometimes suall ganglia appear between 



I 
I 

J 



DRiCBIPTIOy OF PLATES IV ato V. 

IlliMtfsting y, W. Jaitreboff's paper on the Normal and Patho- 
logical Anatom J of the Ganglion Cerricale UterL 

Plats IV. . 

Fia. 1^ — The pelTW of s newlj-bom fnuJe child. Tbe riglit os inBoru- 
Batam rcnored. PL Plexnt hjpogMtrieiu. a, Gmnglia utero-Tcsicalia. 
t, QaagiaM, recto-TiguialuL e, Twigf oi ncnl nerra. s. Utems. «. Btadder. 

Fio. 2d — ^Two gBoglU in one microMopiad teetion (from the FrmnkenhjEUjer 
ganglioo). Hartoack f . 

Plats V. 

FlO. 3.— Part of a normal ganglion, prepared with osmic acid. a. Nerre- 
cellii. b, TranxverMlj cut myelin nerve-fibres, e. Blo'jd.ressels. d. Peri- 
ganglionic connectiTe tiicae. e, Loo«er tiwoe fnrronnding the ganglia. 
y. Nerve bnndlen ninninf? to the ganglion. Hartnack |. 

Fio. 4. — Part of a pathologically altered ganglion, prepared with osmic 
acid. a. Nerve-cellfl. b. Periganglionic connective tiasne. c. Growing endo- 
ganglionic connective tisbue. d. Looser tisane surrounding the ganglion. 



OBSTETRICAL TRANSACTIONS Tr-OLXXdl 




OBSTETRICAL TRAHSACTLOHS 




f'M 



"VVV 




OF THG QANQLIOK CEBVIOALE L 



271 



the groups, at other tiraea the number of the ganglia 
appears to be increased. . While this is not of nnich 
moment, it is important that the Prankenheeuser ganglion 
consists of many ganglia, which oan be made out macro- 
scopicallj. Here I must remark that I speak only of 
the nerve-ganglia which constitute the cervical ganglion 
of FrankenhEenser, taking no notice of the ganglia which 
are usually found at the side of the vagina and of the 
ntems. In this way I conclude from my investigations 
that the cervical ganglion of Frankenheeuser is a nervoas 
plexus (in a histological sense) with ganglia enclosed 
within it. 

Investigation of pathological examples will give us 
some light on the importance of this plexus for the 
uterus and ovaries. Here I must remark that the pre- 
parations examined by me were not previously treated 
with acids, and I therefore worked as if the plexus was 
a solid muss or as the ganglion of Frank enh its user, I 
did this because I wished at a later stage to use 
osmic acid, and therefore considered the previous use of 
acetic acid as inadmissible. Consequently, also, I speak 
in the hereafter adduced cases in general of the changes 
in the ganglia which form the anterior part of the solid 
mass or ganglion of Frankenh tenser, that is, those which 
^H constitute onr anterior group, or of the changes in the 

^H posterior group which form the posterior part of the solid 



The investigated oases are : 

I. Polypoid prominence of a part of the placental ineartion 
(^atonia uteri placentarie partialis) ; intertliiial inflam- 
mation of the ganglia forming the anterior part of the 
cervical ganglion of Frankenhaiiser ; secondary fatty 
degeneration of the nerve'Celle of the anterior group of 
ganglia. 
On the 16th April, 1880, 6—, set. 26, was admitted for 
her confinement into the maternity. Menstruation com- 
menced at fifteen years. Her first pregnancy and labour 



I 



L 



272 NORMAL ASD PATHOLOGICAL ANATOMY 

was seven years before admission. Her labour was 
normal. She did not nurse the cHld. The last menses 
before the pregnancy was iu August, 1879. The length 
of labour was five hours and a half. The placenta was 
removed by the Crede method, a small piece remaining 
iu the nteriue cavity, which could be removed only on the 
second day after delivery. On the 26th day the woman 
died with signs of pyaemia, left side pleuvitis, peritonitis. 
Mid purulent synovitis of the left knee. On the posterior 
uteriuo wall at the fundus, at the seat of the insertion of 
the placenta, we found a swelling projecting into the 
cavity. It was of the size of a walnut, elongated in form, 
and rough. On section it was found to be composed of 
utvriue wall. 

Micrwscopical iuvestigatiou showed that the stmcture 
of the swelling was identical with that of the uterine wail, 
hAviog no difference fivm the well-contracted parts. We 
)mtil, ihewfoTO, to do with a polypoid projection of the 
lite of i&«ertioi\ of the placenta into the uterine cavity, 
wilUont cori*9jwuding depression of the outer part of the 
ut«rint> wait. 

Examtnatiou of tlio nerve ganglia revealed changes in 
Ui» HUterii.tr group on both sides. We found an inter- 
•litia) change with conseqaent fatty degeneration. In 
iW \Uv>rWB no pathological condition was found which 
evwld awoHut for the polypoid growth. But the change 
in Iho gnuglin (and its localisation only in some of them) 
Wm Uw ohl to bo dopendout on the disease which had led 
to (ln> fatal went. On the contrary, it may be suggested 
llial ii\ iVHBijqHpnce ot the change in the ganglia those 
}iarti> of the uterus to which twigs from the diseased 
Ipauglia pr^>ceedod had lost their contractility. 

It. Kvtttmjma during and after labour; death ticelvc hours 

i^rti-f ihlivfty i tuetrorrhagia ; atonia uteri ; fatty 

^if^tHvrl^lili» if the iterve~cell8 of the ganglia of the 

•ittrrior yiVNj> <>^' the plej.-ii3. 

Oil ^th February, 1879, the farm labourer F— , set. 24, 



^ 



I 



OP THB gakglion cervicalh dtbbi. 273 

came to the clinic of Prof, Slawjansky, there to await her 
confinement. Menstruation commenced at eighteen years. 
Pregnant for the first time. The last menses before 
pregnancy were in May, 1878. On her arrival she had 
an attack of eclampsia. No albumen in the urine, and no 
element forms. Labour was completed by the Kristeller 
method; the placenta removed by the Crede method. 
Severe bleeding was stopped by ergot of rye. After the 
third eclamptic attack she became comatose, and died 
twelve hours after delivery. The nterus was large and 
flabby; its tissue, microscopically examined, normal. 
Especial attention was paid to the relation of the con- 
nective to the muscular tissue. 

The already mentioned changes in the plexus were 
found in the ganglia of the anterior group. We therefore 
hold the fundamental cause of the uterine inertia to be 
the nervous system, for the uterine tissue was normal. 
Probably the inertia depended on the disease of the 
ganglia. 



III. Cirrhosis of the liver; aacitea ; fibrO'myxoma of the 
ovaries; chronic metritis; interstitial injlammaiion of 
tJie ganglia of hoth plexuses. 

On April 10th, 1880, farm labourer P— , sat. 38, waa 
admitted to the clinic. Menstruation first appeared at 
nineteen. At twenty-seven she was married. In her 
twenty-eighth year she had her first child, and was not 
ill after it, being quito healthy till January, 1880, but 
ifter this time she observed increased size of the abdomen. 
On the 13th April she died. 

Microscopical investigation showed a chronic inter- 
stitial inflammation of the uterus. The ovarian swelling 

I a fibro-myxoma. In the ganglia of both groupa and 
of both plexuses was found an interstitial change, and we 
cannot decide whether it is primary or secondary, but 
their connection with the disease is 8elf*evident. 

VOL. xxiii. 18 



L 



276 AHATOMT 0? THB OASOUOH CKfiTICAM UTBEI. ^ 

1. The cervical ganglion of Frankeuhasnserj as a j 
separate organ, is merely the result of r bad method of J 
preparation. I 

2. The ganglion of Frankenliasuser consists of many I 
ganglia, and is therefore a plezns in the histological seoBO I 
of the word. I 

3. The ganglia forming the pleiaa are divided into two I 
groups, which are connected with one another by nerva I 
bondles. I 

4. Both groups of ganglia are found at the junction of 1 
the twigs from the sacral nerves with that of the hypo- \ 
gastric plexus. j 

5. The position of the plexus corresponds to the posi> \ 
tion of the cervical ganglion of Frankenhieuser, but not i 
to the position of the utero-cervical ganglion of Lee, or of 
the plexus primus and aecundus of Walter, 

6. The plexus is in adults smaller than Frankenheeuser 
has represented it. 

7. The plexus is not like those plexuses of authors who J 
do not recognise the ganglion of Frankenhseusor. J 

8. To make out the plexus macroscopic ally, reagents I 
must be used which make the tissue looser and trans- ] 
lucent. 

9. There is a patent connection between the diseases of 
the plexus and those of the uterus. 

10. On disease of the ganglia most probably depends 
functional disease of the uterus in the different stages of 
labour. 

11. Simultaneously with disease of the uterus the 
ganglia of the anterior group of the plexus undergo 
lesions. 

12. There is a connection between diseases of the 
ganglia and those of the ovaries. 

IS, In them it is the posterior group of ganglia that 

are affected. 

14. The comparative ages ot the diseases of the ganglia 
d of the ovaries can bo determined only by observation 

ot a great number of cases. 



jia. 



SPASMODIC DYSUEIfORBB(EA AND StERlLITr. 277 

Both the macro- and microscopical preparations were 
laid before Professor SLawjausky. 



THE TREATMENT OF SPASMODIC DTSMENOK- 
RHCEA AND STEEILITT BY DILATATION OP 
THE CERVICAL CANAL WITH GRADUATED 
METALLIC BODGIES, WITH NOTES OP PIVE 
SUCCESSFUL CASES. 



By Clemekt Godson, M.D., M.R.C.P. Load., 







NBOK LTIHD-IN BOBPITAt; 


: PHYBICIAM-i 




BTHOLOMBW'S BOBPITAl; 










SOCISTE or LOMLON. 





As the heading denotes, I do not propose to ester apon 
the large Bnbject of dyemenorrhoea, but to apeak only of 
that kind known as epasmodic or obstructive, and in this 
paper I record only the cases occurring in married 
women, where sterility was associated with it. It will be 
understood, however, that the treatment applies equally to 
spasmodic dyamenorrhaa in unmarried women, many 
successful cases of which I could have brought forward. 

This method of treatment by dilating the cervical canal 
with graduated metallic bougies was suggested to me 
quite recently by my colleagne, our President, Dr. 
Matthews Duncan, and it was the success which I had 
observed follow the practice in his hands which induced 
me to adopt it. I am aware that his example and teach- 
ing has led many others to give this mode of treatment 
a fair trial, and they will, I bope, give ua the result of 
^m their experience. The advent of our President to this 
^H metropolis has, I believe, been the occasion of resusci- 
^H tating among us a treatment which had fallen into dis- 
^H repute, and had given way to other methods supposed to 
^H entirely Bapersede it. 



280 SPASMODIC DTSMKNOHBH<EA AND STEHILITT. 

girl, Eet. 22, the subject of amenorrhtea — or emansio meji- 
viurti — for she had never menstruated, but wlio since 
sixteen years of age complained regularly every month of 
pains in the loins, together with a sense of weight and 
bearing down in the pasBages, latterly so severe as to in- 
capacitate her for work ; Ending on examination that 
the OS uteri was a mere depression, he conceived the idea 
of dilating the canal, and accordingly commencing with a 
small triangular probe, went on until he succeeded in 
introducing a No. 6 male bougie to the fundus of the 
uterus ; the result was that menstruation was immediately 
established, and proceeded regularly without pain or 
inconvenience, 

Ab there is no record of swelling before the operation, 
or escape of retained menstrual fluid subsequently, no 
better evidence could be brought forward against the 
obstructive theory. No doubt the probing acted as a 
stimulus to the uterus, resulting in the menstrual dis- 
charge. 

This case, however, suggested to Dr. Mackintosh the 
use of metallic bougies for the treatment of dysmenor- 
rhcea, still entertaining the idea of obstruction, although 
he saya :*— " I am far from alleging that dysmenorrhce.i is 
always produced by a small os uteri ; on the contrary, I 
believe it may occasionally depend on inflammation of the 
lining membrane of the uterus, as wall as on inflammation 
in the substance of the cervix uteri, and on the encroach- 
ment of tumoui-s diminishing the calibre of the passage 
through the cervix." 

Dr. Mackintosh proceeds to say that he employed the 
dilators in twenty cases of dysmonorrhcea, permanently 
curing eighteen ; ten only of these were married, living 
with their husbands, all were sterile, and seven subse- 
quently fell with child. This is the statement made in 
1639. Since that time he had tried the practice in seven 
• 'Principles of Fathologj nnd Practice of Phjiio,' by John MackintOBli, 
M.D. Loudon. 1836, vol. ii, p. 431. 



BPASUODie DySUENORR-HlEA AND STEEILITT. 



281 



other cases after all other means had failed ; in one of the 
seven only did it fail, the other six were completely and 
permanently cured, and four of these bore children. 

It appears, therefore, that out of seventeen married 
women, eleven, who were previonsly barren, became preg- 
nant. Several of the cases are published in extenso ; one 
woman had been married between seven and eight years, 
another three years, and so on. 

He says : — " The instruments employed to produce the 
dilatation are the common metallic bougies, of different 
sizes, from that of the ordinary silver probe to No. 14. 
The operation is performed (the patient lying in the posi- 
tion in which women are usually delivered in this country) 
by introducing the index finger of the left hand till it 
reaches the os uteri, for the purpose of directing the 
instrument to the part, which is then to be gently iusinu- 
ated by a rotatory motion till it arrives at the fundus 
of the uterus. Much force ought not to be employed." 

With regard to the length of time after the dilatation that 
impregnation took place, "three months afterwards" is 
mentioned in one case, and " some months afterwards " in 
another. 

I find that the bougies were exhibited by Dr. Mackin- 
tosh at the Liverpool meeting of the British Association, 
and they are described as "like long knitting-needles." 
It is evident, therefore, that they were straight, as they 
are stated to have been by Sir James Simpson before the 
Medico- Chirurgical Society of Edinburgh, July 3rd, 1844. 
By the kindness of Professor Alexander Simpson, of 
Edinburgh, I am able to show yon two of these bougies ; 



^H aba] 



one is in»pked No. 4, the other 14. It will be observed 
that the points are excellent as regards their conical 
shape. 



282 SPASMODIC DTSMUSOEHHlEi AND 8TBBIL1TT. 

" In speaking of dilatation of the os and cervii: uteri m 
a means of care for dyBmenorrhoea, Dr. Simpson pointed 
out the resnltB of this practice in the hands of the late 
Dr. Mackintosh in the core of dysmeoorrhtea and sterility 
connected with normal and inBammatory atrictures of the 
OB nteri. His own results had not been ao successful aa 
those of Dr. Mackintosh, but he had now seen a consider- 
able number of severe cases in which dysmenorrhcea, that 
had previously resisted all other kinds of treatment, had 
at once yielded to the mechanical dilatation. Dr. Simpson 
had found the stricture occasionally at the os internum or 
opening between the cavity of the cervix and body, 
and not at the os tineas. Dr. Mackintosh had effected 
the dilatation by long straight bougies of different 
sizes. Dr. Simpson had found them more easily used 
when slightly curved. Latterly, Dr. Simpson had in his 
practice thrown them aside, and used permanent bougiea 
or stems made of Berlin silver, and he considered them 
far preferable."* 

I quote this at length to show that Sir James SimpsoQ 
used them with enccess though he discarded them, and 
that he was apparently the first to curve them as they ara 
now employed. 

The next note I find about them is in ^ A Prootiotit 
Treatise on the Diseases peculiar to Women,' by Samuel 
Ashwell, M.D., London, 184.8. He says:— "And Dr. 
Ryan entirely cured one of the very bad forms of dys- 
menorrhcea by metallic bougies. As the introdnction of 
bougies must act as a direct and powerful stimulus, thfl 
advantage, even when constriction really exists, may not 
be entirely attributable to dilatation." 

Baker Brown, in the ' Surgical Diseases of Women,' 
1866, p. 285, speaks of elastic tubes like catheters, of 
different bores, which he passes over a stilette first intro- 
duced into the uterus. He quotes two cases of ladies, one 
married three years, aged twenty-seven, the other, aged 

* ' LoDdoD and Edinburgh Monthly Joarual oF Medical Sciei 
18U. p. TU. 



I 



^M the iatn 

^H without 



8PABU0D1C I)T9Ma»0RHHCEA AND STBEHITT. 283 

thirty-one, twice married, both sterile and Bubjeots of dys- 
menorrhceaj who, after dilatation, lost their pain and 
became pregnant. 

Next comes a violent adreree criticiam. In the 
'Lancet,' March 4th, 1865, and following numbers, are 
pabliehed lectures by Dr. Marion Sims, which were after- 
wards compiled in a volume entitled ' Uterine Surgery,' 
We find the following : 

" M'Intoah dilated the cervis with bougies, but who- 
ever has followed him must have been struck with the 
uncertainty of the result as well as with its painfulness, 
to say nothing of its danger, A priori it would seem a 
trifling thing to pass a bougie along the cervix uteri, but 
I have known it to be followed by most serious results." 
He goes on to describe a case in which he passed on one 
day a small bougie, next day a larger one, and two or 
three days afterwards a conical bougie, dilating the os 
externum to about a No. 9. There was a. slight lacers^ 
tion of the contracted os. The patient nearly died from 
metro -peritonitis. He adds :—" This was my last boogie 
case ; I have known several cases of the same sort in the 
hands of others in my own country, and I have seen two 
in Paris during my short sojourn there." 

It will be observed that the bougies were not passed at 
one sitting, bat at intervals of a day or days, and that the 
OS uteri was split. This is sufficient to account for the 
untoward consequences. If Dr. Marion Sims and his 
friends had passed the bougies one after another in gra- 
dation, he would probably have had better results. I can 
only say that I have seen now a very considerable number 
in my own hands and those of others without a single 
catastrophe happening. At the same time, I have seen 
inflammation of the womb aud its surroundings follow the 
passage of an ordinary uterine sound, where no difficulty 
was experienced, and I have seen disastrous effects follow 
introduction of a large male catheter into the uterus 
previous dilatation. No manipulation about the 



284 



SPASMODIC DTSHENOHBHtEA : 



cervix ateri is abeolately free from dangerons coQBeqaeiicdB. 
There would be no difficnity in finding plenty of such 
in connection with division of the cervix, which Dr. Marion 
Sims upholds. 

In the ' Lancet ' for April 8th following. Dr. Gream takes 
op the defence of dilatationj and says: — "I have seen 
pregnancy repeatedly, and often immediately, supervene 
upon the same operation for cnre of dysmenorrhoea in 
married women." 

Soon aCter this, on June 7th, 1865, a paper was read 
before this Society by Dr. Barnes, entitled " On Dys- 
menorrhcea, Metrorrhagia, Ovaritis, and Sterility, depend- 
ing upon a pecnliar formation of the Cervix Uteri, and the 
treatment by Dilatation or Division," Dr. BartieB Bays : 
— " If dilatation were proved to be more safe and effica- 
cious than incision then it ought to be preferred. Evi- 
dence is conflicting. I cannot, however, estimate lightly 
the circumstance that men of great experience, sagacity, 
and resources, like Simpson and Marion Sims, have 
abandoned dilatation in favour of incision. They have 
found dilatation neither safe nor efficacious." Dr. Barnes 
advocates the division only of the external os uteri ; he 
speaks of a great quantity of glairy mucue that sometimes 
escapes from the canal of the cervix after the incision. 

Dr. Matthews Duncan, in a paper on dysmenorrhcea in 
the ' Edinburgh Medical Journal,' May, 1872, describes 
the operation as performed between two monthly periods, 
and it consists in introducing as large a bougie as will 
easily pass (a No. 10 or 11 in the ordinary male urethral 
series) ; on each successive day a larger bougie is intro- 
duced, till after several introductions, say seven, a large 
boogie is passed {a No. IS or 19 in the ordinary 
male urethral series). This is the method recommended 
by Dr. Duncan, and in his ' Clinical Lectures,' lately pub- 
lished, he says : — " These various numbers are not all nsed 
in one day, but on successive days, or every second or 
third day, and generally the whole is effected in a few 
flittings, say, from four to eight." 



SPASMODIC DTSMENORBHiEA AND BTEEILTTT. 



285 



In a very interesting and instructive paper in the 
'British Medical Journal' of November flth and 16th, 
1872j entitled " Researches on the Mechanical Dilatation 
of the Cervix Uteri, and the appliances used for the pur- 
posej" Dr. Duncan showSj as the result of experiments 
deBcribed] that each dilator expands to the extent of about 
'02, or one fiftieth of an inch, beyond that immediately 
preceding it in the series, and the bougies in Dr. Duncan's 
case are numbered according to this extent of dilatation. 
No. 13 would, therefore, expaud to '26 inch, or about a 
quarter of an inch in width. Dr. Duncan lays much 
stress on the point of the dilator being of a conical shape. 
He concludes tbat "dilatation without causing a wound, 
is safer than, and therefore preferable to, dilatation by 
cutting or tearing instruments which do wound ; also that 
dilatation quickly or by instruments which arc not allowed 
to remain is safer than, and therefore preferable to, dila- 
tation slowly or by instruments which are left for hours 
or a day in the passages. 

Dr. Aveling and Dr. Atthill, in commenting on this 
paper in subsequent numbers of the journal, object to this 
dilatation on account of tbe force required to bo used. 
The slightest push means force ; beyond this really the 
wori force is misleading, gentle continuous pressure is all 
that is required. Force »niiBt be used, however gentle and 
easy. No considerable force should be used. 

I have treated altogether ten cases of dysmenorrhtea 
in married women in whom pregnancy had not occurred. 

In one of these the dysmenorrhoea was much diminished 
during the two periods which followed the dilatation. It 
then returned as badly as ever, and I decided to introdnce 
a silver stem, and leave it in the uterus. This case is 
referred to later on. She has been cured of her dysme- 
norrhcea, but pregnancy lias not followed. It is only fair 
to state, however, that her husband is seventy years of age. 

In tour of tbe other cases the dysmenorrhoea was cured, 
but as far as is known pregnancy has not resulted. One, 
a hospital case, has been tost sight of. Another had her 



a ^ 



- " 



286 SFASHODIC DTSUGNOBBHCEA AND aiERTLITT. 

cerrii divided by tte metrotome before coming andar my 
treatment. In five of the ten patients pregnancy occurred. 
The notes of these are as follows : 

Case 1. — On May 5th, 1880, I received a letter from a 1 
gentleman in the North of England, paying that a lady was 
deairons to consult me for the reason that she had been 
married several years and, not having had any children, 
was anxioua to satisfy herself if there were any possibility 
of her becoming a mother. On May 24th she came to see 
me by appointment. I ascertained that she was thirty- 
two years of age, had been married four years, and was in 
good health, with the exception that she had a good deal 
of pain at her monthly periods ; this had increased ainoe 
marriage, it varied very much in its severity, and was of 
a spasmodic character j only occasionally did it lay her up. 
Since marriage the menstrual Ioeb bad been very profuse, 
it had always been somewhat eo. The last period had 
terminated four days since. I found a somewhat small 
external os uteri, and the uterus slightly anteflexed j the 
cervix was in its shape and size natural. The sound 
entered without difficulty, but with considerable pain, two 
inches and three quarters ; I subsequently passed Nos. 7, 
9, 10, 11, 12, and 13 dilators, leaving each in a few 
minutes. As each succeeding dilator passed the pain 
experienced was less severe, it was of the character of that 
experienced at the monthly times. It should be noticed 
that the complaint of the patient was sterility, not Aya^ 
menorrhcea ; the latter was bearable, and but for the 
former she would not have applied to me. I directed 
her to see me again after menstruating twice, and to then 
appear soon after a period. 

She presented herself on July 30th, stating that there 
had been a marked decrease in the pain on each occasion, 
it had not at all incapacitated her. On this occasion I 
passed Nos. 6, 8, 10, 12, 13, and 14 bougies ; the pain wag 
less than on the previous visit, there was no discharge of 
blood. I adviBed her to have patience, and to oome 



I 



SPASMODIC DTSUIBOBIlHaiA AHD STESaiTT. Wl 

and see me again in six mootliB if elie did not become 
pregnant. 

I heard no more o£ her till April 21at, when I received 
a letter full of gratitude, informing me that she expected 
to be confined early in August — and I have since aeen the 
announcement of the event. From this it appears that 
she hecame pregnant towards the end of October, having 
menstrnated three times since I last passed the dilators. 

Cask 2. — Mrs. W — was sent to me by Mr. White, of 
Margate. Aged twenty-nine, had been married eight yeara, 
never pregnant. The catamenia commenced at the age of 
seventeen, have always been regular, very scanty, always 
very painful, worse on the first day, comparatively little 
afterwards, bat is left very weak from the severity of the 
pain on the first day. The pain is in the hypogastrium, 
and is like so many knives cutting in ; it is not constant, 
there are periods of repose, It gets worse each time now, 
sometimes makes her sick and roll about on the bed. The 
last period was a fortnight ago ; it waa the worst, entirely 
preventing her from leaving her bed for two days. 
Having a great deal to do, managing a boarding-house, 
she decided that she mnst give up her employment it she 
coald not get relief. Has a good deal of leucorrhoca, 

rse before, and after being unwell, it is flaky. Has a 
freqaent desire to micturate, 

Examination : per abcionieit.— Tenderness in hypogastric 
region ; per vajjmawj.— Cervix long, os somewhat small, 
no anteflexion ; both ovaries can be felt, the right appears 
swollen and is very tender. Sound passea with much 
pain, two inches and three quarters. Dilators 7 and 8 
passed ; could not proceed further as the pain during the 
passage of each was so great that the patient screamed 
out, and vomited the contents of her stomach. I noticed 
that a quantity of viscid mucue passed with each dilator, as 

it had been pent up in the canal of the cervix. I 
ordered a tepid douche and a mixture of bromide of ammo- 
oinm with oitrate of irooj and heard no more of her till a 



288 BPASMODIC DYSMBKORBHOCA AND STERlLITt. 

few months afterwards Mr. White added a postscript to 
a letter about anothor patient. — " You quite cured Mrs. 
W — , whom I Eont to you suffering from dysmenorrhcea ; 
she had one period after she saw you, without any pain, 
and immediately afterwards became pregnant." 

Case 3. — Mrs. L — , ast. 22, married two years, applied 
to me on April 26th, 1880, complnining o£ impairment of 
health since marriage. The catamenia commenced at the 
age of sixteen ; always suffered pain at these times, but 
since marriage had suffered agonies^ retching violently. 
To use her own words, she had been to eight doctors for 
it, and none of their medicines gave her any relief. She 
objected to be examined, was a nervons woman, full of 
pains everywhere, the only tangible complaint being the 
dysmenorrhoja, which she described as occurring suddenly 
the day before the flow appeared, attaining its height on 
the first day, and subsiding on the second, spasmodic iu 
its character at first, leaving subsequently a feeling of 
aching in the lower abdomen and back. I prescribed for 
her general health, and for the dysmenorrhoaa gave her 
the following mixture, which I have fonnd very useful in 
similar cases iu young unmarried girla ; 

9i Liq. AmmoD. Acetatii, f3iiji 
Ammouii Chloridi, ^ijj 
Tr. BelUdoDiiEe, fjij ; 
' Sp. Chlorofonni, tyiy. 

Aqua CHUph. nd f^vj. 
A liztb part to be Ukeii immediatetj tbe pain occart, uid to be 
Mp«at«d In lliT«e or four liours if not relieved. 

This prescription, although it was said to considerably 
mitigate the pain, did not cure it. The general health 
improved but little, notwithstanding a prolonged visit to 
the seaside. On September 27th I made an examination. 
The cervix was short, os somewhat small, and the uterus 
fiomewhat anti^flexed. I passed the sound two a half 
inches in normal direction with considerable pain ; I could 
not persuade the patient to allow me to pass more than 



SPASMODIC I>Y8M 



AND STERILITY. 



289 



two dilators, Noa. 7 and 8 ; each was left in about five 
minutes. The three following periods were comparatively 
free from pain. She then became pregnant, and I 
delivered her on September 15th of a child weighing ten 
and a half pounds. 

Case 4, — Mrs. T — , aat. 24, married two and a half 
years, consulted me on October 23rd, 1880. She had 
anffered pain always during the periods, generally com- 
mencing with the first flow, though feeling ill for two days 
previously with much backache. The pain is chiefly in 
tho hypogastrium and right iliac region, of a very acute 
character, lasting for several hoars, alternating in iutenaity. 
It is accompanied by numbness in the legs, especially the 
right. There is almost invariably sickness at this time. 
The symptoms have been aggravated since marriage, and 

! getting worse. The periods are generally regular. 
Cannot bear the slightest pressure round the waist. 
Bowels irritable, constantly acting without diarrhoea. This 
was the statement, not elicited by questions, but brought 
by her, written out by the husband. The digital exami- 
nation discovered nothing abnormal beyond tenderness on 
tilting the cei-vix backwards and forwards. There was 
slight antefiezioD. The probe passed two inches and 
three quarters, with severe characteristic pain, I 
succeeded in passing Nos. 7 and 8 dilators, when the 
patient began to retch, and declared if any more had to 
be done she must have chloroform. In conversing with 
her subsequently I remarked, " I should not be surprised 
if you became pregnant after this." She showed great 
displeasure, and said she would never have come near me 
if ehe had had any idea of such a probability. Their 
limited income permitted herself and husband at present 

I to have every comfort, and to have a small house in a 
fashionable locality, but a child would upset everything, 
she would not have one for the world. She had never 
had a symptom of such a thing. 
On December Slst, eight days subsequently, I was sent 
, TOL. sxiii. I'J 



I 




i 



ifn JhAf 27A riM iM«4 lUl far « 

( f(/ft>* mm hm lrM« tW b*i 

hMVff m (KtM fTMl!* fiMW< 

f )tM( mw hAT tm thftmiher 1Mb wfcca Ae ngav3 
pm^tttmf.f nun fnrTjr wtoM l irfigJ. ~ 

ivntr fffxyi iiJMw iliA A\\Mtttit bftd 1 

f MffW r*f«y trrifff/ (« lite t-MM) of « Udy, Kt. -33, who 



^H SF&SJtODrC DYSMENORRiirEA AND STERILTTT. 291 

had been man-ied for eleven years, her husband being 
now about seventy years of age. They had no settled 
abode, and preferred to travel about, staying chiefly in 
hotels. She suffered from spasmodic dysmenorrboea more 
severely than any patient I ever met with. When the 
pain was at its height she would roll on the bed and 
scream like a woman In severe labour, so that the hot«l 
proprietors complained of her. All the remedies she had 
tried only relieved her slightly and temporarily. When 
she applied to me I passed only two dilators, Nos. 6 and 
7 ; they gave rise to the characteristic severe pain, and I 
had difficulty in persuading her to allow me to introduce 
the second bougie. She left London, and camo to see 
me three or four months afterwards, saying that though 
the pain had been certainly less during the two or three 
periods following the dilatation, it had returned as badly 
as ever, I proposed repeating the operation, but she 
begged me to try something else that would be more 
permanent in its benefit, as she wanted to go on the Con- 
tinent before very long. I agreed, therefore, to try a 
eilver stem pessary, and accordingly inserted it at her 

I lodgings, keeping her in bed for a day or two sabse- 
quently. The next period was passed without pain, but 
during the following one the pain suddenly occurred, and 
being in Bath she sent for Dr. Colo, who found it in the 
vagina and reinserted it, with almost immediate relief. 
The same circumstances occurred not long afterwards 
when in London, and I decided then to introduce a Wynn 
Williams shield beneath it. This had the desired effect, 
and for upwards of twelve months the patient wore it, and 
travelled about on the Continent, suffering no pain what- 
ever. I had great difficulty in persuading her to allow 
me to remove it. Now, however, she menstruates without 

I it free of pain, and is in perfect health. 
In this case the dilatation was very imperfectly per- 
formed, and there were other eircamstnnces connected 
with her married life against the probability of her 
becoming pregnant. 



lSMODIC DYSMENOBRIKEA J 

Of my five Buccosetul cases the ages of ' 
woro roRpectively 32, 20, 22, 2t, and 25, and their terms 
of inarriod life 4, 8, 2, 2i, and 3i years respectively. No 
doubt it will bo argued that the last three cases are weak 
oil ftocount of the shortness of these periods. I do not 
nttOKipt to say that it left to nature some of these patients 
niight not hare at some future time become with child, 
but no one will deny that if a young healthy woman live 
iu fretjuont intercourse with a vigorous husband, and does 
not boconie pregnant during a period of two years and 
upwards, an impediment must exist somewhere, and I 
have every reason to conclude that in my cases the im- 
pediment lay in the condition of the womb which gave rise 
to the dysmouorrhcea, and that as soon as this was recti- 
fiod the barrier was overcome, and pregnancy occurred. 
It matters little, therefore, whether the patients had been 
married two years or eight, bo long as the dysmenorrhcBa 
still existed. 




I present to you the case of dilators which I use (m 
diagram) ; yon will observe that I have arranged them ] 
that they occupy but little room, and can be carried m 
the pocket, one handle serving for all. I have lately 



SrASMODIC DYSMEMOERHcEA ASD STEBILITI 



293 



I 



Been a small case manafactured by Messrs. Kroime and 
Seseman for Dr. Edis, showing that the same idea origi- 
nated with him; I had no notion of this till long after 
mine was made for me by Messrs. Arnold and Sons. 

In conclusion, I submit that the five patients whose 
histories I have related are sufficient to show that dilata- 
tion of the cervical canal by graduated metallic bougies is 
a treatment not to be put aside and discarded. 

Notwithstanding the severe criticism of Marion SimB, 
and its acceptance by other distinguished gyuEecoIogistSj I 
venture to say that the method properly conducted is not a 
dangerous one — is, indeed, safer than any other. The first 
bougie passed should be a small one, and there should not 
be sufficient difference between the size of it and that 
which follows to cause a splitting of the cervical canal, 
an occurrence which is likely to arise under other circum- 
stances ; the dilatation should, therefore, be performed at 
one time, and not on successive days, as hitherto recom- 
mended. 

I do not mean to assert that dilatation by bougies is 
always successful ; if it fail, other modes of treatment 
may be tried, the insertion of a silver stem, for instance, 
as in the last case I uaiTated, or division of the cervix. 
But I look upon these as more complicated and attended 
by more risk. I have seen so much harm follow the care- 
less iutroduction of stem pesaariea that I never venture to 
insert one without keeping the patient at absolute rest for 
two or three days afterwards, whereas the process of dila- 
tation can bo conducted with safety in one's own consulting 
room, the patient walking away and returning home after- 
wards. 

And, with regard to incisions, I waa in the habit of 
just nicking the sides of the external os with the punc- 
turing lancet in the out-patient room, until several 
cases of infiammatory mischief causing fixation of the 
uterus followed, and I waa compelled to discontiuoe the 
practice. My cases show that a very small amount of 





ltiflpo«{b>e tfc«l u Caa»:tisBi 
ft largH pTijf of crAgnlfttod 
to Oon« «ir*y danng' ttte 

f/thpr I ^nd m three -if il 

fjMriff "''Vfl '>f trom t'wo to fisar- 

lUtifiiN ion frnm a plo^ o£ iniiMi%, 

iliPr. ■ -Mi. 

fir ..^4 frranil ()i*t is the iarj^ nujocttj' itf 

fAtMiltff IWnniial of tlw UleTui ia ft «tat« of vtrughtiuwB. fit 



'ASaODIO DYSMKNOREIKEA AND STKEILITY. 



295 



I 



^^m than 



cases where the titeruB was undulj soft and pliable dilatatioa was 
Dot necessary, but in long- a tan ding cases dilatation was a gr&at 
aeaisUnce ia the treatment. He had used as a dilator a two- 
bladed instrument acting on the principle of a glove stretcher. 
It produced the same kind of effect as the dilators now 
exhibited. He had cured many cases of sterility, some of tea or 
even thirteen years' standing, by the above treatment. In regard 
to diagnosis, cases of very soft flexed uterus were sometimes over- 
looked, as in a case be mentioned, owing to the apparently easy 
passage of the sound. He considered Dr. Godson's paper a 
very interesting one, and dilatation an important method of 
treatment. 

Dr. Hktwood Smith said that reference had been made in 
the paper to the President's experiments as to the flow of fluid 
through bent tubes ; but whatever their substance and material, 
Dr. H. Smith contended that such eKperimenta failed in their 
analogy to the uterine canal, for such tubes were homogeneous 
in their structure and uniform in their calibre, whereas the 
uterine canal was of varying thickness and of such a substance 
as rendered its canal obnoxious to impressions on its inner 
surface from any flexion that it was subjected to. He con- 
gratulated St. Bartholomew's Hoepital in having so long ago 
initiated so sound a line of practice as that referred to in the 
paper, and also of carrying out that practjce up to the present 
time. For it was in IB'66 that his father, then assistant lecturer 
with Dr. Bigby, used Mackintosh's bougies for the treatment of 
dysuenorrhcea and sterility up to 1848, and since the foundation 
of the Hospital for Women that method of procedure had been 
practised and taught with the greatest possible advantage, as 
his colleagues would also be able to testify. He considered the 
graduated sound exhibited was not of the best shape, being too 
much curved. The best shape woo that of the ordinary sound, 
straight in its handle and straight also as to its uterine portion, 
and having a raised collar to mark the length of the uterine 
portion. The graduated sounds are also of great ^vantage 
when it is desirable to use intra-uterlne medication, for the 
sound can be used with the greatest facility up to No. 10 or so, 
and then the introduction of Playfair's probe is thereby rendered 
oomparatively easy, besides which all risk of using tents is 
thereby obviated. 

Dr. Caktrk said he quite agreed with the writer of the 
paper as to the good results which follow the dilatation of the 
cervical canal in such cases by the use of graduated sounds. He 
had obtiuned exceedingly satishictory results both as regards 
dysmenorrhcea and sterility when it accompanied it. He did not 
think he had incised the cerrix uteri for dysmenorrhcea more 
than ten or twelve times during tha laat aeven or eight years. 




-"*• {Mbft tmiatpm U tfau of Dr. 

.^Mhl bMl * hi» 1 1 ■■■■■i III! WMnl 
-i by t^ 1MB Dfc. JooM Um*^ tmt ife 
^ TM* «■■ saaB «• &«• nC dutgcor aa 

• . '>*>« iimmiamui. Wfeai, moreover. 

■. .1 *mi □»-. TIanja Snaa h^d <tt>carded 



>«. be taai ktem 
1 £i>ttmi au obatmct 

r Aiuuii biLtl bewK] 
' ' 1 uii<r*^ obstnictioB' 
'.' 'lu cuutlitioa was 
: both he and Dr. 
■- ■.■iaiintirter of pain, 
nodiciilly. 



4 



'- ^p^ 






: ihi4 ha<) to be 
rt hii'li geaerallT wa§ i 
Tlius, the iia,ia kk 




DYSU&NORBHtGA AND STBRlLtTT. 297 

hv pasaing the bougie is very great. It was so in some of Dr. 
Qodsou's cases. Did not this piove there vas some degree at 
least of subacute inflammation and congestion F Clearly, there- 
fore, it was right to use depletorj measures first, and then yon 
could safelj proceed to dilate. But the very dilatation by tents 
led to absorirtion of thickened parts, and the iulra-uterine 
pessary often kept up for a time a loss of blood ; such relieved 
the uterus. But all these dangers and difGculties were enhanced 
by flexing, yet none of Dr. Godson's cases were complicated by 
flexion. Every gyuEecologist knew how difficult it was in some 
cases of flexion to pass a bent sound into a uterine cavity. It 
also often gave rise to serious accidents. Was it philosophical 
in sueb cases to use straight or scarcely curved bougies. To do 
so woulil provoke inflammation, and otherwise be useless. With 
either Dr. Williams' intra-uterine pessary, or his (Dr. Bouth's), 
a, uterus was not only kept dilated till the dysmenorrhcea was 
cured, but it reduced the uterus. The comfort of such instru- 
ments well used vras such that women did not like to part with 
them ; a few wished to retain them to prevent pregnancy, but Dr. 
Koulh always removed them after eight or twelve months, not to 
prevent, but to make pregnancy more sure, and, he was hapmr to 
say, this frequently followed the use of his instrument. Even 
Dr. Godson had applied in one of his cases an intra-uterine stem, 
which, pro tani-o, proved his plan was defective, and, more than 
this, he was obliged to use one of Dr. Williams* shields, 
showing the need of a support to keep the pessary in tiUX, 



Ik. 



I 



INDEX. 



Addreu (Annual) of tht FretidetU, Wm. S. Playfmr, M.D., 
February 2nd, 1881 .... 

(Inaupiral) of the new Fresidmt, J. Uatthewa Duncan, 

M.D., March 2nd. 1881 

Anwtal General Meeting, February 2nd, 1881 

AuteBexioD of the uteroa, on the relation of, to dyimeuorrhiei 
(Q E. Herman) .... 

AvEhino (J. H.) Remarki on W. R. Rogers's case of inversion 
of the nt«rus .... 

in discussion on G, E. Herman's paper on the rela- 
tion of anteflexion of the ntema to djBmenorrhcea 

in discussion on Hey wood Smith's vase of removal of 

a large fibrous polypus 

Report aa Chairman of Uie Board for EiaminatioD of Uid- 



i 



Bantock (G. Q.) see A. Doraa. 

Babnks (Fanconrt) Bmnarka on 0. Godson's cases of depres- 
sion of frontal bone 

instrument designed by Dr. C. Duncan, of Borne, for 

measuring the amount of flexion existing In the utema 
(shown) ..... 

Bemarhs in discnasion on J. Braithwaite's paper on 

capsuluted fibroids .... 

BaKKBS (Robert) " missed labour," so-called, with a ca 
Ulnstration .... 

adjourjied diteueiion on ''missed labour" 

Bemarke in reply .... 

note on the so-called " lithopiedion " being a supplement 

to the author's paper on the so-called " missed labour " , 



" 




^Littbew^ Danes 



Cb.ir 



, H. li^i^ 






^■u:a[ '} 



•t .[■.wr'Wiii.-.n '.'a C <>yiii'in"i papT ■■.n the -*~t-titii 
' «y.>-*iiii.-i'.'i' .'.T-jmea'jrrhfi'a mil iit^rilify hy ililitMtaoB 
J,'. .'.UJJ. ;'.'■• d'lmatiijn of, in tho f rnj>tm*fnt of •!] 
t.,-.-.r.-.'rr>.v.' ir.d rtonli-r <"; OMv.nj 



■T-::-p.' 



1 .■'I'h hr,*!! r 



I 



Champneys (P. H.) incomplete rupture of vagina; the uterua 

and neighbonring parts (sbowa) , 
Bemarfce on A. Doron's microscopic seotionfl of dermoid 

- — * on A. Doran'e case of arrested development in fratua 

in diaouBsion on Percj Boulton's caae of imperforate 

Tagina ...... 

Oletbland (W. V.) flesh; substance discharged from uteras 

(ahown) ...... 

— — ■ Semarke in diBCnasion on the histology of cancer of the 

body of the ntems (A. L. Gatabin) 
Report on his specimen of fleshy substance dischurgod 

from uterus ..... 

CoLB (Beverley) spring pessaries (shown) . 

on the late Alfred H. McOlintock 

Copemon, Edward, M.D., of Norwich, obituary notice of . 
Oronk (H. 6.) see Godgon. 
Oyats, see Ovariim. 
see Tanumrt. 



Degeneration, villous, of the endometrinro (D. 0. UocCallum) 
Development, arrest of, in geui to- urinary tract in a female 

fcetuB (A. Doran) ..... 
Dewab (J.) interstitial fibroid, see Godton. 
Dilatation of the cervical canal with graduated metallic 

bougies in cases of spasmodic dysmenorrhcoa and sterility, 

with notes of five successfiil cases (C. Glodeon) . 
DOBAN (Alban) exfoliation of vesical mucous membrane 

(shown) ...... 

microscopic sections of a dermoid ovarian cyst (shown) . 

Romarhi in reply ■ . . . , 

arrest of development of genito-nrinary tract in a female 

fcetns ...... 

Semariit in reply ..... 

for Q. 0. Bantock, cyst of the great omentum (shown) 

Bemarka on O. Hoggan's specimens of the lymphatics of 

the uterus ...... 

on specimen of double ovuriutomy (Uiitthews 

Duncan) ...... 

in discussion on the histology of cancer of the body 

of the uterus (A. L. Oalabin) .... 



Gaiabin (A. L,) case of estra --uterine aseociated with iatra- 
uteruie ftstation, in which abdominal eection was performed 

RemarltB in reply ..... 

histology of cancer of the body of the nterus, microflcopic 

sections shown ..... 

— — ease of pregnancy compliciited by cancer of the cervix 
uteri, followed by pyosmia associated with eymptoms simti- 
lating diphtheria ..... 

periodical discharge of membrane in cervical endo- 
metritis; microscopic sections (shown) 

Eemarks on D. C. MacOallum's case of villous degenera- 
tion of the endometrium .... 

in discussion on B. Bamea's paper on the so-called 

" missed labour " ..... 

- ■ ■■ in discussion on G. B. Herman's paper on the rela- 
tion of anteflexion of the uterus to dysmenorrhrea 

Report on W. L. Cleveland's specimen of fleshy sabstanoe 

discharged from uterus .... 

Ganglion cerricale uteri, the normal and pathological anatomy 
of (N. W Jastreboff) .... 

Geni to- urinary tract in a female fcetus, arreat of development 
in (A. Doran) ..... 

Gbbtis (Henry) modification of Hodge's pessary (shown) 

BiiiinrfcB in discussion on B. Barnes's paper on " missed 

labour" ,...., 

in discussion on G. E. Herman's paper on the rela- 
tion of autofleiion of the uterus to dysmenoiThisa 

in discussion on J. Bi'axton HicVs's case of twins, 

with short funis in both .... 

Kepwl as Treasurer for 18S0 . . 42 

Gestation, see PTcgnancy. 

Godson (Clement) depression oF the frontal bone in two 
infanta (shown) ..... 

Stanarka in reply ..... 

for J. Dewar, specimen of interstitial fibroid causing 

retroflexion of uterus ..... 

Fallopian gestation (shown) .... 

Leiter'a tempci-ature regulator (shown) 

Marshall's patent sectional feeding bottle (shown) 

for U. 0. Crtmk, a. malformed heart (shown) 

an umbilical cord in a. state of cystic degeneration 

(shown) ...... 



Godson (Clloment)/or Arnold Thompson, surgical pocket case 

(Bbown) ...... 

the treatment of Epaemodic dysmenorrhiEa and Bterility 

by dilatation of tbe cervical canal with graduated metallic 

boagiea, with not«e of five successful coses 
— Bemarht on Alban Doran's specimen of vesical muoous 

membrane ..... 
in discUBHion on B. Barnes's paper on the so-called 

" misud laboor" ■ . . . . 
in discussion on A. L. Galabln's case of pregnancy, 

with cancer of the cervix nteri 



Eayes (T. 0.) anteflexed atems (shown) . 

~ Remarks in discussion on J. Braxton Hicks's case of twins, 

with short fiinis in both .... 

Head, ftetol, plaster casts of {J. Bmnton) . 
Heart, a malformed (C. Godson) .... 
Ueath (W. Leuton) notes on the dissection of a malformed 

child ...... 

— Bemarkg in reply ..... 
Hebuan (G. E.) blighted and atropliied embryo (shown) 
on the relation of antetleiion of the uterus to dysmenor. 

— B«i>Ktrks in reply ..... 
ditto ..... 

— Translucent sac, microscopical preparations from a speci- 
men ...... 

— Bemarka in discussion OQ J. Braithwaite's paper on non- 
oapsnlated fibroids ..... 

in discussion on A. L, Galabin's case of pregnancy, 

complicated by cancer of the cerrix nteri 

in discussion on W. L. Heath's notes on the dissec- 
tion of a malformed child .... 

in diBoassion on A. W. Edis's case of epithelioma 

after oerriz with pregnancy .... 

— Btport as Hon. Librarian for 1880 

Ebwitt (Graily) Remarks m discussion on J. Uatthews 
Duncan's case of phlegmasia dolena 

in discussion on C. Godson's paper on the treatment 

of spasmodic dysmcnon-htsa and sterility by dilatation . 
BlCKiMBOTHAM (J.) notes on a ca«« of placenta pnevia com- 
plicated by a large myoma .... 
VOL. ZXIII. 20 



HlcxntBOTBAM (J.) B*«iMirit» in reply 

in discawion on J, Braxton Hicks's case of twinu 

irith abort funta in boLh 
HtCKa (J. Braxton) pregnancy mih double ut^tus and vagina 
^— Vftitjcal sepliitu in lower part of Tagiaa impeding labour 
■ caae «f twine, sbort funis in both 
Brmartt in discussion on Mattbens Duncan's paper on 

Bhonoeaa of tlte oord M ft CMise of obstructioii to the 

BktuTftl progTQM of labour 
UoooAM (O.) eompanttire uiktomj of the lymphatics of the 

ntonts (speoiiiiens) . . . ■ 



n R. Barnes's paper c 



178 

265 



ImebOH (Jftmea) Btmarhs 

the •o-called '' missed labour 

jASTRKBorF (N. W.) on the normal and pathological anatom; 
of the giuglion cervic-ole uteri 

Labour, see Parhtrititm, 

Lboiakd (H. a.) double OTariotomy, see Dunean. 
Leiters temperature regulntor (C. Godson) 
Lift qf Offietn SIkM/ot ISSl 

qfdmofitrlS^ . . . i .V 

— -- (/jKut Frttidemii .. . . vi 

<|fB«/«r«.o/ Paper* /br 1882 . . . vii 

' qf Standing CommiHev* . . yiii, ix 

qf Honorary Local Secroforie* . . . x 

qf Honorary Ftlloiog . . . xi, xii 

Iff Corretponding Fellowt .... liii 

qf Ordmary Fellcmi .... xiv 

of Decta*td FelloKt [with obituary notices, which see] 55-60 

'■ LitbopSHlion," so-called, heing a supplement to R. Barnes's 

paper on the so-called " missed labour" . . 170 

Lymphatics of th« uterus, comparative anatomy of (G. 

Hoggan) . . . , .4 

Lymphatic varix, case of phlegmasia dolens with (Matthews 



11) 



133 



MAcCALnmt (D. C.) yillouB degeneration of the endometrium 
McGlintock (Alfred H.) tribute to the memoiy of the late 

[motion of condolence on his death] 
Jlalformations, child (malformed], notes on the dissection of a 

(W. L. Heath) ..... 



Mulformations, anencephaJoid fa'tue (H. C. Pope) . . 1 

(F. WaUace) . . .2 

deformed fcetua in a case of ntero- vaginal rupture, 

placenta previa, and multiple fibroids (A, Wiltahire) . 1 

heart (malformed) (0. Godson) . . . 1 

MarBhall'H patent sectional feeding bottle (C. Godson) . 1 

Meadows (Alfred) pessaries of sylonite (showa) , , 1 

Meeting, Annval General, Febmary 2nd, 1881 
Membrane, periodical discharge of, in cervical endometritis 

(A. L. Gfllabin) . . . . .2' 

vesical mucous, eifuliation of (A. Doran) 

Uidwifery, statistics of, in private practice (0. Bigden) . 1. 

"Missed labour," so-called, with a case in illuBtration (R. 

Barnes) , , ' . . . ' 

' adjonrned discusaion on , . , 1 

UuBRAT {G. G. p.) Eemarkg in discnssion on Heywuod Smith's 

case of removal of a large fibrous polypus . . £ 
in discussion on J. Braxton Hiclis'a case of twins, 

with abort funis in both . . . .2 

Uyoma, a large, in a case of placenta pruvia (J. Hickin- 

botham) . . . 1< 

Obilaary noliees of deeeated Fellowt . . £5- 

MsWrlj, Wm. H, M.D., of Copcmnn, — . M.D., of Nor- 

We»t KensingWQ - . 55 wich .... 

Wnllier, Alfred, M.D., of BHteinaii,H]'.Chu.,F.R.C.S,. 

Hertford .... S6 of IiUogUin . 
Fairbink. Tho*., U.D., of Kiuoli, Prufe»gor Francwco, 

Wiiidior .... 65 of Boli^na 
Omentum, cyst of the great (A. Doraa) . , . L 

Ovarian dermoid cyst (J. Knowaluy Thornton) I' 

microscopic sections of (A. Doran) . . 1' 

tumonr with the Fallopian tube adherent to the Opposite 

ovary (J. Knowsley Thoraton) . . 2J 

I Ovaries, extirpation of atems with both (T. Ohambers] 
Ovariotomy, doable (Matthews Duncan) 
Parturi 
toi 



Parturition, on shortness of tbe cord as a cause of obetruvtion 
to the natural progress of fabour (Matthews Duncan) 
" missed labonr," so-called, with a case in illustration 
(R. Barnes) ..... 

B o( plac«nta prtevia complicated by a large uyoma 
(J. Hick inboth urn) ..... 




L 



(M G. K. Hmn^ paper am therela- 
«■ C Oa*n^ paper <» tk timt- 

f ia prTta<« ptactiee (Q. B^jea) 

dOatatioB of tlM ccnical canal vitk graJaafad mrtaltin 

boog^ witk BotM cf five ■iK^M^fal cmm (C. Godaon) . 

Sa^cal poctci eaae, Jgaignn j bj A. noaipaMi (C. Oodaan) . 

Thompsok (Arnold) aee GodMtm. 

TH085T0S (Ejiowil«j) dennoid cyst of orarj (eltown) 

OTBiian tomonr, with the Fallopian tube adherent to th« 

opposite ovary (shown) 
Btmtarkt on G. Roggan's epecitnens of the lymphatics 

of the utemB .... 

on Hpecimen of doable ovariotomy 

Tuitjoara, cyst* from the labia minora (A. Wiltshire) 

dermoid cyst of ovary (Knowsley Thornton) 

ditto (A. Doran) 

fibroid, complicating delivery (W. 8. Playfair) . 

iion-capBalat«d, resembling retained placenta (J. 

Braithwait*) 

interstitial (C. Godaon) 

fibroids, mnltiple, in a case of titer o -vaginal ruptnr^ 

placenta pnevia, with di'formed foitae (A. Wiltshire) . 163 1 

fibroma of the ntema (Heywood Smith) 

■ large myoma in case of placenta pnevia {J. Hickia- 

botham) ...... 167-1 

.^— ov&riiUi, with the Fallopian tube adherent to the opposite 

iivary {J. Knowsluy Thornton) 
— removal of a large Gbrona polypus (Heywood 
Twins, oonjoined, case of (Percy Boulton) . 
. short (iinis in both (J. Brsixton Hicks) 

Umbilical curd in ii state of cystic degeneration (0. Godson} . 180 ' 



Umbilical cor3, on the shortness of the, as a cause ofobstrBction 

to the natural progress of labour (Matthews Duncan) 

short, in a case of twins (J. Bi*axton Hicks) 

Urethra, female, calculi embedded in (Ma-tthevs Duncan) 
Utems and appendages, showing rupture of tubal fcetation (C. 

Godson) ...... 

and ncighbonriiig parts, in a cose of incomplete rupture 

of vagina, shown b; F. H. Ohampneys . 

onteflexed (T. 0. Hayee) .... 

on the relation of anteflexion of the, to djamenorrhcea 

(G. E. Herman) ..... 

histology of cancer of the body of the (A. L. Galabin) 

double, and vagina, case of pregnancy with (J. Braxton 

Hicks) ...... 

delivery in a case of (Matthews Duncan) . 

eitirpation of. with both ovaries (T. Ohaoibers) 

. — ' interstitial fibroid causing retivllezion uf (C. Godson) 
— — ttbroma of the (Heywood Smith) 

Hcahy Bubatance discharged from (W. F. Cleveland) 

Report on specimen of fleshy substance discharged from, 

by A. L. Galabin, John Williams, and W. P. Cleveland . 
instrument designed by Dr. 0. Duncan, of Bome, to 

measure the amount of flexions existing in (Fancourt 

Barnes) ..... 

chronic complete inversion (W. B, Rogers) 

lymphaticsof the (G. Hoggan) 

polypi uteri (A. W. Edis) 

cerrii nteri, cancer of (A. L. Galabin) 

cervical canal, the dilatation of, in the treatment of spas- 

modic dysroenorrhcea and sterility (C. Godson) . 
ganglion curvicalo uteri, the normal and pathological 

anatomy of (N. W, Jastrebofl^ 
epithelioma uf the cervix with pregnancy (A. W. Edia) 



Vagina, case of delivery through an imperforate (Hirywoud 
Smith) ...... 

case of imperforate (Percy Boolton) . 

vertical septum in (J. Braxton Hicka) . 

incomplete ruptare of: uterus and neighbouring parts 

shown by F. H. Chompacys .... 

and ut«rus, doable (J. Braxton Hioks) . 



312 



PASS 

WAr.LACE (F) anencepbalous fcetua (Bhown) . . 20* 

Wblm (Spencer) Remarks in diBcnaaion on R. Bamea'a paper 

on " miaaed labour " .... 100 

WiLLiiMS (John) Report on W. L. Oleveland'a apeciraun of 

fleafa; enbatance diechargcd from uterus . 181 

Wiii.iA.MS (Wynn) Remarks in diacuasion on Heywood Smith's 

case of remoTal of a large fibrona poljpus . . 237 
in diacuBsion on J. Braxton Hicke'a case of twine, 

with ahort funia in both .... 255 

Wiltshire (Alfred) specimen of utero-vaginal mptore, 

placenta previa., multiple fibroida with deformed fcetUB, 

ao-oalled cretinoid ..... 163 

cjats from the labia minora (ahown) . . . 206 

Remarks on Dr. Champney'a caae of incomplete mptnre 

of vagina . . .12 
in diacuBsion on 0. Godson's caaea of depreaaion of 

frontal bone . . . . .32 

• ; on W. Bnrton'a caae of eitra-nterine pregnancy , 36 

in discussion on the histology of cancer of the body 

of the utems (A. L. Galabin) .... 162 

in discussion on J. Bmnton'a oaata of a fcDtal head . 207 

in diacuaaion on A. L. Galabin'a microscopic aeo- 

tionu of membrane diacharged in cervical endometritia . 208 
in diacusaion on Heywood Smith's caae of removal of 

a large fibroue polypua .... 237 
in diBcuaaion pa Percy Bonlton's case of conjoined 

twins ...... 262 

in discussion on A. Vf. Edia'a caae of epithelioma of 

the cervix with pregnancy .... 264 



Zjlonite, pessaries of (A. Meadowa) 



131 



OBSTETRICAL SOCIETY. 



ADDITIONS TO THE LIBRARY 



BY DONATION OR PUKCHASB DOKING THE TEAR 1881. 



Presented by 
BALFOUR (P. M.). A Treatiee on Comparatire Embry- 
ology. KOodeuU, vol. II. &V0. London, mSl Furcbaeed. 
BAnNEa (Fancourt). A German-Engliah Dictionary of 
Words and Terme used in Medicine and its cog- 
nate Buiencee. em. 8vo. Lond. I8S1 Author. 
Beelt (F.). Krankdeiten der Hand : 

OerhardI, Kinderkrankbeiten, Band YI, 1880 

Krankheiten dee KopfcB : 

Oerhardt, Kinderkrankbeiten, Band VI, 18S0 

Bitot {Paul). Contribution a I'etude dn mueaniamo et 

du traitement de I'Hemorrhasie Itde a I'lnBertion 

Vicieuse de Placenta, woodcutt, 8to. Paris, 18S0 I'urchaseil. 

BciKAi (J.). Krankheiten dea MastdartneB und dea 

Aft«ra : Oerhardt, Kinderkrankbeiten, Band VI. 

1880 

Bc>aNEB (E.). Ueber daa BubBcrose Uterua-Fibroid 

('Volkroann, Sam.,' 202). 8ro. 1881 

BoaCH (Van den). Kyato Multiloculaire de rOvaire 

Droit. — O»ariotomie. Phenomonea th oraciq uea 

gravee. — Gu^rlsou (from ' Aunal. de Gynecol.'). 

8vo. Paris, 1881 Author. 
(oBCH (H. v.). Presentation de ]Y>pauIe droits, avec 
degagement du braa et procidence du cordon 
ombilical. bvo. Bruseliea, 1881 

EBsiebre de Boisuont (A.). De la Menstruation, con- 
aideri-e daoa soa rapports pbyeiologiquea et pathj- 
iogiques. 8to. Paris, 1842 Purchased. 



Ditto. 



Ditto. 



ADDITIONS TO THE LIBEAEY. 



BauiTEin (Fr^d^ric). Etnde sur lea Eruptions herpe- 

tiques qui se font auz organes genitaun chez la 

lemme. Svo. Paris, 1880 

Buhl (L.). Klinik der Greburtekunde, see 'B.tcker. 

BuBToN (J. E.). Handbook of Midwifery for Midwirea 

(from the Official Handbook of Midwifery for 

PrUBBiau Midwives). woodcuts, 8vo. Lond. 18S0 

BcracH (J, D.). Sftmmlung auserlesener Beobach- 

tungen aua der tecbaiacbea Geburtaliulfe. 

ptalet, 4to. Marburg, 1817 

Candido (Eamello) e Brambiila Luisi. Eeportazione 

TJtero-Ovariea per grave auguatia di Pelvi 

Eauhitiehft, Svo. Turin, 1880 

Capuhon (J.). Trait^ dea Maladies des Eufans juaqu'a 

la pubertiS. Svo. Puria, 1813 

Catalogue of Books added to the BadcliSe Library 

during 1S80. 4to. Oiford, 1881 

Ciitftlogue of Temporary Museum of tbe International 

Medical Congreaa. Sro. Lond. 1881 

Cattlin (W. a. N.). An Address delivered before the 

Aaaoeiatiou of Surgeons prautiaing Dentai Sur- 

gery. Svo. Lond. 1881 

Cazik (H.). Dea Varieea pendant la groeseBse et 

I'accouchement. Svo. Paris, 1881 

CiiAiLLT (M.). A practical Treatise on Midwifery, 

translated by G. 8. Bedford. 

woodcuts, Svo. New York, 1844 
CoL[.KT. See Qurgui. 

CoTTiNO (B, E.). Hiatorical Sketch of the Obstetrical 
Society of Boston, Svo. Boston, 1881 

CocKTY (A.). Traite pratique dea Maladies de I'tTterua, 
des Ovaires et des Trompes ; troisi^me Mition, 

2' partie, woodcuU, Svo. Paria, 1881 
C'uEDfi (C. 8. r.)— Beitrage zur Geburtshiilfe, Gyoako- 
logie und Padiatrik, Peataehrift. 

woodcuts and plates, Svo, Leipzic, 1881 
I. — Uebnrtshiilfe. 

tJber das Credf'sche Vcrfnhrun and diii Narljge- 

bnrlsieit. H. FehUug. 

Higtorisch-cthnograpliiiiclie Natizen zur Bflinndliiiitc 

der Nncligebnrtiiperiode. 11, Plan. 

Vber Gebiirien bui alturon EcatgebiLrEiidcn in der 

1'rivHt.prKiia. P. Orentrr, 

Dur Kuiiieriicliuilt bei Uti'ruiifiLrolDtii ola Qruutllu^ij 



Proam 
Purcbaaed. 

Ditto. 



AuthorB. 

Dr. 

Hall Davi 

Dr. H. 

Acland. 

The 

Coinmittei 



Author. 

Purchase^ 

Dr. 
HaUDarii 




ADDITIONS TO THE LtUBABT. 



einPT TergleichendeD Methodik ier ijormiilcn Sectio 
(^aeurpB und dm Porro-Operutiuu. JU. Sanger. 

2. — Gy niik ologio. 

Dig Lebeiiitdtiner doi Carcinoma Mummiie unci die 

LebeasdnuijT bci Carcmomn HiiniDiiie. C. Uennig. 

Zwei MjoiDBUmiMn loil Veneiikung doa Stiplcs. 

Oeneaiiiig O. Leopvld. 

Cber PrnriCiu uterinM. L. FrocluniiMck. 

a.— Pailitttrik. 

Zwei Typen dea nonnnlon Beoken». A. Fforiep. 

Vbur Ouwicbt ddiI Temperatur bui Nengeborener. 

A. Se/iiiti. 
Uber dio Tbntigkcit dor Brostdrlue dar Neu^etio- 
ronen. Dr. Opilt. 

Zar Pbys'ialogie dee HSrorgans NeDgehoMncr. 

fl'. MoUealutaer. 

Zar mecliikDischen Bcbanillung des Prolnpsua re«ti 

im SiiaglingMlter. L. Fiirtt. 

Cbouzat (E.). De la MenBuratioii tWorfque et pra- 
tique du diametre promonta-pubien mioinium au 
point do ¥ue obatetnaal et d'un Pelvimetre direct 
a art: taugent au pubia. plate, 8vo. Pane, 1881 PurchoBed. 

De-Csistotobis (Malachia). Le Malattie della Donoa. 

Trattato clinico, woodcult, Sto. Milano, 18SI Author. 

Dictionnaire Encjclopf-dique dea Sciences Medicalea ; 
directeur, A. Decbambre. 

Ire Siric, Tom. XXV. XXVI, le. purtie. 

2me „ „ XV. XVI. 

8m« „ „ IX. X. 

4nit' „ „ VI, VII. VIII, IB. pmUb. 

DoLATf (T. M.). Medical BefoFtu: a Reprint from 

' Med. Press and Circular.' 8vo. Halifax, 1881 Ditto. 

Tbo nature and treatment c 

phobia ; Hfuond edition. 

DouAN (Alban). Perforating Ulcers of the Ileum from 
Obetruction after Ovariotomy (from 'Trans. Path. 
Soc.'}. 8vo. 1S70 

— and Vincent Hams. Spinal Cord from a case 

of TetanuB, following OvarioLomj (from ' Trans. 
Path. Soc.'). 8?o. ItiSO 

PapiUouia of the Fallopian Tube, associated ivitL 

t Ascites and Pleuritic Effusion (from * Trans. 
Path. Soc,'). plaU, Sto. I8stt 

DiBsection of tbe O en i to- Urinary Organs in n 
case of Fiaauro of the Abdominal Walls (from 
' Journ. of Auat. aud Phjsiol.'). platt, Svo. IsyO 



I TO THE I.IBBARV. 



Pretented 1 

Purchased. 

Dr. Ailcbia 
Aathor. 
Ditto. 



DcBAA ( Louis -Eugeoe). Des Tubercles de la ^famelle. 
plates, 8vo. Paris, ISSl 

DuFOT (M.)- Des diyerses positions du Fcetus dans lea 
AocouchemeDB. \^At end of Icart, Le^oua Eur 
I'Art dea Accouche mens.] Hio. 

Edis (A.. W.). Diaeasea of Women, including their 
pathology, causation, Bjmptoms, diagnosis and 
treatmoat. waotleutB, Svo. Lond. 18S1 

EuMET (T. A.). Principienund Praxia der GjmBkologia 
iibersetzt von Dr. C G-. Kotbe. 

Svo. Leipsig, 1881 

Ebcolast (G. B,). Atlas of Memoir upon the TJtri- 
cular Glands of the Uterus and the Glandular 
Orgun developed during Pregnancy ; also of 
Monograph upon the Unity of the Anatomical Dr. 

Type of the Placenta ; translated under the Fancourt 
direction of H. O. Marcy. 4to. Boston, 1880 Barnes. 

Ebcolani (G.). Sul Parto Pretermesso o mancato 
nelle Feminine dei Myoiua glia e neUa Specie 
Umana. Svo. Bologna, 1881 

EuBTACHB (G.)- Manuel pratique des Maladies des 

Fenimea. Svo. Paris, 1S81 Purcfaaaed 

Fkhlino (H.). See Oredi. 

Fbbtseb (P.), Ueber die Eweckmassigste Behandlung 
der Nacbgeburtaperiode. Inaug. diaa. 

Svo. HaUe, 1881 Author. 

FociiiJiEK (A.). Lemons cliniquea aur la Syphilis, 
etudice plus particuli^rement chez la femme ; 2e 
Edition, revue et augments. 

plates, Svo. Paria, 1881 Purchased. 

FaiTHCH (H.). Die Krankheiten der Frauen, Aerzten 
und Studirendea geachildert. 

Svo. Braunachweig, 1881 Ditto. 

Fbobibf (A.). See Oredi. 

Fi)RBi> (L ). Miesbildnngen des BiickeninarkB : 

Oerhardt, Kinderkrankbeiten, Band V, 1879 



Oalabik (Alired Lewis). The Students' Guide to the 
Discaaes of Women : second edition. 

wooileuls. 12mo. Lond. 1881 



ADDITIONS TO TUE LIBEAEY. 



GAaBlCOUET (Cadet de). Traits clinique des Maladies 
de I'EnfaDce: Affections du Cieur ; Bheuma- 
tisme; Choree; Coqueluche ; Oreillona ; Vari- 
celle ; Bougeole ; Scarlatine ; Fievre typho'ide. 

temperature diagrams, vol. II, 8vo. Paris, 1882 Purchased. 
QxBHAXST (C). Hnodbuch der Rinderkrankbeiten. 

vols., woodcutt, 8vo. Tubingen, 1879-80 Ditto. 

Erite Abthvi'iuug. 
Eratc H&lftc. 
Krankheiten dei Nene^-Sgtttmn 

Fauctionelltin Nervenknnkheiten. O. Solimam. 

MiBsliUduDgcii des Buckenmarki. L. FUrtt. 

Hjpsraiaie uQil Ulutuag dee Kiickeamarkea. 

UeniDgitU und MjeUtig. O. Kohl*. 

Zweite UHfto. 
Kratikheiteu det Nfrven-Ssiletar. 

Suinnli' Kinderialiniutig. A, SeeligmulUr. 

Kruikboilen dea acbiroa, A. Sleffht. 

Zwcite AbtLeilang. 
Kranliheilen der Mmtcln — dei OthOrorgana ~~ de* 
Aug>t. 
Kmikhciteii der Muaki^lD. M. Sridtl. 

„ des Quhororgujos. A. niit TVoJ/iek. 

„ des Augus. F. Romtr, 

BiSB VX. 
Zweitu Abthcilnng. 
Cla/mTg\Kht* Erkranhingen det Kopfit, da Saltai, 
der SaocAen und QtUuka, der Hand, da t\utit, 
det Mattdamei und JJteri iimj die Eemten .- 

" nKoiife*. F.Bttbi. 

n HiJm. 

F. T^tmdeletAurg i 
Krankbeiten der Euoehea nnd Gctcuke. 

Sd. ve» Wail. 
I KnkukbdtcD der Hand. F. Beelg. 

I „ dc. Fiuae*. X. MmmL 

„ de* MasLdannei uod del Afbn. 

J. BStai. 
Die H^ruieti. Ti. Kt>ch»r. 

GoODwiLliB (U. H.). Surgical Treatment of Kaso- 

pliaryngeal Catarrh (from ■ Mad. Gaz.'). 

Svo. New York, 1880 
Gbaumatixi (J,). £in Myoma cervices uteri caver- 

Dosum (from 'Arcbirf. Oyoiikologie, Band i 



tHeft 1). 
Kara (P.). 



See Ored^. 



plalc; 8vo, Berlin, 1881 SlavianBky. 



818 



ADDlTIONa TO THB LIBRAKY. 



OuBOri (Joaquin Collet y). Die Ovarralsehwangor- 

Bchaft vora path ologiacb-anato mi ache n Stand- 

punkte. ptateg, roy. Svo. Stuttgart, 1880 

IIaht (Dsvid Berry), The Structural Anatomy of the 

Female Pelvic Floor ; ThesiB. 

plates, 4to. Edin. 16S0 
Harvey Statue, The Unieiling of the, at Folkestone 

Svo. Folkestone, 1881 

llECKEE (C.) and L. Buhl. KLinik der Geburtsfcunde, 

2 vols. 8vo. Leipzig, 1861-64 

IlEQiH (A.) and R. Kaetehbacii. Die Operative Gynae- 

kologie mit EinachluBB der gynakologiBchen Dn- 

terBuchuneslehre ; zweite Auflage. 

I und U Ilalfte, woodeuls, Svo. Stuttgart, 1881 
IlKNiriQ (C). See CfedL 

IIknben (V.). PhyBiologie der Zeugung, Bee Hermann. 

IlsRBiNiACX (M. G.). Traite aur divers Acconchemena 

laborieux et but lea Polypes de la Matrice. 

plates, 2 vols. Svo. London, 1791 
Ukhmann (L.). Handbuch der Pbyaiologie der Ernahr- 
ung und Fortpflaoiung ; zweitcr Theil ; Pbyaio- 
logie der Zeugung vou V. Henaeu. 

Svo. Leipzig, 1881 

Hfiitzia (Leopold). Marienbad, its Mineral Watera 

and BalbB ; third edition. Svo. Vienna, 1873 

HoaOAK (Geo.). On Degeneratioo and Eegenemtion 

of the Axis-cylinder in Non-trauniaiic Kerve 

LeaioDB, with apecial referenL'e to Gangrene of 

the Cutaneous Aervea (from 'Trans. Path. Soc.'). 

Svo. 1880 

and F. E. Hoggan. Zur pathologiBcben Histo- 

logie der Bchmerzfaaften Bubcutanen Gescbwulst 
(trom ' Virchow's Archiv f. Path. Anat.'). 

p/a(e,8vo. 1881 

HoBtrsB (F.). Krankheiten dea Augea : QerJiardt, Kin- 

derkrankheiten, Band V. 1879 



Dr. 

F. Bamea 
He. 

G. BaetesJ 



Dr. 

HaUDavt 



Purcfaai 
Author. 



ilu 



CEB (John). Works with Notes, edited by Jas. F. 
Palmer. 
4 vols. 8vo., Kit\ vol. of plates, 4to., Lend. 1835-7 



Hall Davis. 
Dr. Allcliin. 



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Presented bi/ 

JntKS (B. W.). Atresia of the Genital PaBsages of 
WomeQ (from ' Chicago Med. Joum. and Exam.'). 

8vo. Chitttgo, 1880 Author. 

The Eelationa of Goitre to Pregnancy and De- 

rangemtnia of the Generative Organs of Women. 

bvo. New York, 1881 Ditto. 
XiLiur (H. F.). Daa haliBteretiache Becken in eeiner 
Weichkeit und Uehubarkeit withrend der Geburt. 

plates, 4to. Bonn, 1857 Purchased. 
KiacH (£. Henrj). Marienbad and its natural 

healing agents. 4to. Marienbad, 1879 Author. 

Klkihwacuteb (L.). Gmndrisa der QehurtBhiilfe fiir 
praktische Aertza und Studireude ; zweite 
Auflage. KoodcalB, Svo. Wien, 1881 Purchased. 

KocnKK (Th.). Die Hernien : Gei-hardt, Kinderkrank- 
heiten. Baud VI. 1S80 



KoKBcn (Dr.). Ueber die Beweglichkeit der Gelenk- 
verbindungen des Berkens (I'rom ' Zeitschrift fiir 
GeburtshiilfeundGynakologie,' Band VI.Helt 1). Prof. 

Svo. 1881 aiayiansky. 
Labat (Emmanuel). HochercheH cUniques eiperiment- 
bIcb aur la Tete du Pa'tue, au point de rue 
obstetrical. woodcuts, Svo. Parifl, ISSl Puri-hafip<l. 

I Lahs (Dr.). Die A chaenzug-Zangen mit beaonderer 
Bcrucksichtigung dor Tarnier'achea Zangen ; 
eine geburtehiilfliche Abhandlung. 

plates, Svo. Stuttgart, ISSl Ditto. 
Landau (L.). Die Wanderniere dor Frauen. 

woodculs, bvo. Berlin, 1681 Ditto. 
I Lamsis (H. G.). How to Use the Forceps, with an 
introductory account of tho Female Pelvis and of 
the Mechaniani of Delivery. 

woodeutt, Svo. New York, 1880 
I IiAPIs ( — ). Zur Casuiatik der Verletzungen der 
Busaeren Q esc h lech te-organe des Weibes bei 
Skoptzen (from 'Archiv fur Oyoakologie,' Bund Prof. 
XVII, Heft 1). ptalea, Svo. Berlin, 1881 akviimaky. 

IfliAiiTB (C. G.). De la Cacheiie S^ubq des Enceintes 
et dea Accoucbcee (These). 

Ito, Strttabourg, 1S52 Piuchiiacd. 



Dr. Fancoiirt 
Baru«B. 



320 



ADDITIONS TO THE LlBRABr. 



Fretttnied, 
Lz BilLLY (A.) Etude clinique but la Nevralgie ileo- 
lombaire Bjtuptomatique dea Affections doa 
Orgsnea G^nitaui choz la femme. 

Svo. Paris, 1381 Purcbased. 
Lee (R.). Lectures on the Theory and Practice of Dr. Hall 

Midwifery. vsoodcute, Svo. Lend. 18U Savia. 

Leoendbe (H.). Stnde sur ia Scartatine chesi lea 

femmea en couches. Svo. Paris, ISSl Piirchi 

Leuuans (Johannes a.). Funiculi Umbilicatia Uumani 
Pathologiam. Diss. luaug. 

jtlalet, 4to. LipeisB, 1737 Ditto. 
Leopold (G.) See Orede. 

Lebov (Alpbonse). La Pratique dea Accoucfaementa. Dr. Fsncoi 
8vo. Paris, 177G 

Esaat BUT I'hietoire naturelle de la Grossesse et 

de r Accouchement. Svo. Geneva, 1787 

Letter from a Male Phyaician in the country to the 
Author of tbe Female Pbysician in London. 

Svo. Lond. 1726 Purohi 
Litzmahu (C. C. T.). Daa Scbrag-ovale Becken mit 
beaonderer Berucksichtigung seiner Entetebung 
im Gefotge eineeitiger Coxalgie. 

plates, folio, Kiel, 1853 
LrsK (W. T.). The Science and Art of Midwifery. 

illuitrated, Svo. New York, 1882 
Macaki (F.). L'Ostetricia in Genova. 

Svo. Genova, 18S0 

■ Prelezione lettain GenovaU 19 Novembre, 1S81. 

Scuole Ostetriciie Italiane e Strauiero. 

Svo. Genova, 1881 

B. Clinica Oatetrica di Genova Anno Acca- 

demico, 1880-81, brevi cenni, 

Svo. Genova, 1881 
Mason (Lewis D.). A Statistical Eeport of 252 Coses 
of Inebriety treated at the Inebriates' Home, Fort 
Hamilton, L S. Sco. 1881 

Meadows (Alfred). A Manual of Midwifery : 4th edi- 
tion, revised and enlarged, assisted by A. 5. 
Venn. tcoodeuU, 12mo. Lond. 1882 

Mknsel (E.). Krankheiten des Fuaaea : QerkardC, 
Kinderkrankheiten, Band VI. 18S0 

MiNATi (Carlo). OatetricJa Miuore; lezioni. 

UKfodcutt, Svo. Milan, 1681 



I 



ADDITIONS TO THE LIBBAKT. 



Fat and Blood : and bow to 
12mo. Philad. 1877 

Lectures on DiBeaaee of the Ner?ou8 System, 

especially in Women, diagramt, 8yo, Lond. 1881 

MotOBirsAUBB (W.)- See Orede. 

Monti (A.). Hyperamie und Blntung des RiickeQ- 

markea : Oerkardt, Kinderkrankbeiten, Band V. 

1879 

MoBlEZ (Bobert). La Chlorose : These, 

platei, 8vo. Paris, 1880 

MuHDfi (Paul F.)- The DiagnoBie aod Treatment of 
Obflcure Pelvic Abscess in Women, with remarks 
on the differential diagnosis between Pelvic 
Peritonitis and Pelvic Cellulitis (from ' Arcliiv. 
of Med.'). 8vo. New York, 1830 

MoaPHT (J.). Case of Successful Double Oyariotomy 
done Antiseptically. Svo. Lond. 1879 

Ndnk (B. J.). Female Diseases ; tbe result of Errors 
in Habit and Hygiene during Cbildbood and 
Puberty ; with remarks on the treatment of 
Bachialgia with Igni-puncture (Paquelin's Cau- 
tery). Svo. Augusta, 1881 

Opitz (Dr.). See Oredi. 

PicQTj£ (Lncien). De I'lntervention Chirurgicale dans 
le Cancer de rUti-rus. Svo. Pam, 1890 

Playfaih (W. S.). Notes on the systematic treat- 
ment of Nerve Prostration and IlysterJa con- 
nected with Uterine Disease (from ' Lancet '). 

Svo. Lond. 1881 

Plobs (H.). See Crede. 

Pkochownick (L.). Ueber die Auakratzung der Gebar- 
mutter (' Volkmann, Sam.,' 103). Svo. 1881 

See Oredi. 

Bkicheet (E. T.). Contributions to the Study of the 
Toiicology of Cardiac Depressants. Part 1 — 
Carbolic Acid (Ext. ' Amer. Jl. of Med. Sc.*), 

Svo. PhiUdelphia, 1881 

Bkubold (Sigmund). Uber Verletzungen des Knpfes 
nnd der Olieder der Kinder durch dem Oeburts< 
akt selbst, und durch Einwirkungeo iiusserer 
Gewalt auf den Unterleib der Mutter naUrend 
der Schwangerachaft, und deren gericbtsarztlicho 
Bedeutung. flaie, 8vo. Stuttgart, 1881 

TOL. XXllI. 



Pretented bj/ 
Purchased. 



Author. 
Ditto. 



Purchaaed. 
2L 



ADDITIONS TO THE LIGRAfiT. 



Ercbs (AuGueT C.)- Wovs qutedftm ObBervationes circa 

fltrutturam vQBoriim in Place ula Humana et 

peculiarem hujus cum utero neium. 

plale, 4to. Tubingffi, 17Si Pi 
BiCHAKcaoir (W. L.). Manual Dilatation of tbe Os 

Uteri as a Moane of inducing Premature Labour. 

8vo. Boston, 1S81 Author, 
Sanoeh tM.). See Crede. 
ScauLTzE (B, S.). Die Pathologie und Therapie der 

LageveranderungCQ der Gebarmutter. 

woodcuU, 8to. Berlin, 1881 Furchasat 
Ueber Indication und Methode der Dilatation 

des Uterus (from ' Wien. Med. Blatter '). 

8V0. Wien, 1879 Author. 
Zur Klaratellung der Indicationen fiir Behand- 

luQgder Ante- und Hetro-versionen und-fleiionen 

der Gebiirmutter, teooiicuts, Svo, Leipzig, 1879 Ditto. 
Zur Kenntniss von den UrBachen des Icterus 

neonatorum (from Virchow'B ' Archiv fiir Patho- 

log. Anat.'). Svo. Berlin, 1880 Ditto. 
Zwei gjnaekologiacbe Preiaaufgaben (from 

'Wien. Medizin Blatter'). 8m ISSO Ditto. 

Lebrbueii der Hebammeakunst ; eecbato Auflage, 

leooJculs, Svo. Leipzig, IsSO Ditto. 
SchCtz (A,). See CredS. 
Seeliomullek (A.). Spinale Kinderlahmung: Oer- 

hardC, KinderkrankLeiten, Band V". 1880 

Seioel (M.). Krankbeiten der Muakeln : Gerhardt. 

Kinderkraukbeiteo, Band V, 1879 

Simpson (A. E.). On Aiia-Traction Forcepa. 

8vo. Edin. 1880 Ditto 
Skene (Alexander J. C). Diaeases of the BUdder and 

Urethra in Women. 

woodculs, 8to. New Tork, 1878 Purchased 
Smith (Heywood), Djamenorrhoea ; its Pathologj and 

Treatment. 12mo. Lond. 18S1 Autboi 

SoLTMANN (0,). Functionellen NerveDkraukbuiten : 

Oerhardt, EJnderkrankbeiton, Baud V. 1879 

StaI'FEB ( — ). De THydrorrbee pendant la Grosaesse ; 

Theae. ito. Paria, 18S0 Purchaa* 

SxKFFEN (A.). Krankbeiten dea Gebiriis: Oerhardf, 

Kindorkrankbeileu, Band T. 18^0 



Presented by 



Dr. Hall 
Ua?iB. 



8teif (G. W.). Annalen der Geburtshiilfe iiberhaupt 
und der EotbindungsaiiHtalt eu Marburg ins 
besondere. 

5 parts in 1 vol. 870. Leipzig, 1S08-H 

SwABiUEKDAM (Jubn). Miraculum NatursD. sive Uteri 

Muliebris fabrit-a, ootia in Job. van Home Pro- 

dromum illuntrata, et tabulie. Dr. F, 

plates, 12mo. Lond. 1680 Barnes, 

Tasmeb (ThomaB Hawkes). A Practical Treatise oa the 

DiaeaBee of iDfancy and Cbildbood -, revised aad Dr. Meadows 
enlarged by Alfred Meadowa ; ilrd edition. and 

Sto. Lond. 1879 Dr. Venn. 

Thobbubh (John), On Metria : and on the Dual 

ClJaickl Charaatemtics of Metrial Blood-Poison- 

ing, 8to. Mancbester, 1881 Author. 

[ Thehdelenbcbo (F.t. Erkrankungenund Operationen 

I am Halae; Oerhardl, Kinderkrankhoiten, Band 

VI. 1880 

TaiJLTBcH (A. von). Krankheiten dea Gehor-organea : 

Oerhardl, Kiuderkraukheiten, Band V. 1879 

Valbsta (Aloia). Soil den Hebammon eine operative 

Hiillelciatung bci friacben Mittclfleiacbrtssen 

gesetslieh gestattet seia F 

■ Ueber den sogeo. Coitus repervatus, ala eine 

Uauptureacbe der chroniachen Metritis und der 
weiblichea Nervoaitat (from ' Memorabilien'). 
8vo. Heilbro 
T£ii£oAS (Wilfrido). Essai but te Cancer Hjjtro-Pori- 

ton^al ; These. 4to. Paris, 1876 Purchased. 

\ TmcKMZO (M.). Due Pelvi con deformaKione rara per 
Uancauza Congenita della sinfiei publca. 

8vo. Mibm, IKSl Author. 
iToLKUANit's Sammlung klinlscher Vortrage: 

193. ProchtxBnicIc, Ueber dio Aaibratiaag der Qabinulltter. 
SOS. Sorter, Uclier ibu labierOie Utenu-Fibroid. 
fWiUL (Ed. von). Krankheiten der Knochen and 
Geleuke: Oerhardl, Kinderkrankheiten, Band 
VI. ISSO 

I Wabskige (A.). Essais pratiques du dernier module 
du Forceps Tsrnier (Eit des " Ann. Gjnecologie,' 
July, 1881). 8vo. Paris, 1881 

- Ablation d'une Tumeur Kystique d'une partie 
dti Tuti^rue et do rovaire gauche ; operation trus 
compHqu^; guifriBOQ. 8vo. Brnxelles, 1881 



Author, 



, 1880 Ditto. 



Ditto. 



Ditto. 



BM ADDmOHS TO THE UBBAKT. 

W**«RiaK (A.)- Dm On&rttiotii Obatetric&lea, coon 

UrofiwmJtl'UnitrBmtA dp I.t.'-xe. Uto. Pftrii, 1881 Pi 
Wmhkh (M. I.). Did Uhre vnn ileii Ur- und Sjuxa- 

I^urnidi) der SohiUliit und Becknti Jcs Ueiucben. 

platM. iUi. DuMeldorf, 1830 

Wli.uniiToK (W. W.)- Ilitignilibk&l Sketches of 

Divt^Awd Motnbvra of tlio ObaK'tHcBl Society of 

»..»li)ii. (il»o. Boston, 1381 

Wthl.iAMa (J ). AbdomiriKl FuU&tion, Bitnulating 

AuMuriim urtboAbdomiuAl Aurta (from 'AuetnU. 

Mnl, Jouni.'). 8to. Helboume, 1880 

WiTKHWim (O. I.), Lb Gi^n^ration Hum&ine. 

tcooitcult and platet, Svo. P&ria, 1881 Purcl 
WltmoKiiit (Honr. Auk.). DbitervatioDeB Anat«iiiico- 

Dbklrtrii'im do Htructurn Ovi et Secimdioaruiu 

lluiiiiiiiaruni, iti [mrtu mnturo. 

ptatf, 4to. Ooettingie, 1783 Dil 
i!wiirai. (?.}■ Lulirbuch dcr oporativen OoburUhulfe 

fUr ArKlv und Mtudircode. 

wMileutt, 8vo. Stuttgart, 1881 Di 



TRANSACTIONS. 

AHanlCitN nTiritCOLOOICAL SOOIETT — 

TrniiHKutioiii, vol. v. 8vo. BoHton, 188 

AuKttiuAK Mkdical Ahhogiatiov — 

Tnm<actioM, voL iixi. 8to. Philad. 1880 Abb 

Akatomical and Sdroical Sociktt (of Brooklyn) — 

Annals, 1880^1 8vo. Brooklyn, 1880-81 Exduugi 

Clinical Societi of Lowdok — 

TranBBCtiuns, vol. xiii, liv. Svo. Locd. 1881 Sode^, 

Ihtbenational Medical CoiraBESB — 

Abstracts of tbe CommuaicationB to be made in Ths 

the various Sections. 8ro. Lond. ISSl Com 

Ltoicb SocuSri deh Scienceb M^idicaleb — 

Mt^moires et Comptea-rendus, tome xriii, 1878 

Svo, Lyon, 1879 
Mkuicai. (Eotal) and Cbibubgical Society— 5 

TraDsactions, vol. Isiv. Svo. Lond. 1881 Ditto. 

OustxtbioaL SociETT (Edinburgh) — 

TranMctions, Seasion 1879-SO, vol. t, p&rt 2 ; 

SoasioD 1680-81, vol. vi. 8to. Edin. ISSl Ditto. 



ADDITIONS TO THE UBRART. 


13 


SuirnaoNiAif IssTiTnTiON — 


Presented by 


Annual Eeport of the Board of Regenta for 




1879. 8vo, WMhington, 1880 


Institution. 


SOCIETA MeDICO-ChIBCBOIOA IV MODKSi— 




Atti, 1879-80. 8V0. Modena, 1880 


Society. 


JOUENALS. 


Calendar of University College, London, for 1881-82. 


Council of 


8vo. Lend. 1881 


College. 


■ Incorporated (The) Law Society ; Calendar for 1881. 




H 8to. Load. 1881 


Society. 


REPORTS. 




HospiTALB.— Bartholomew's (St.) Hospital Reports, vol. 


Hospital 


xvi. 8vo. Lond. 1880 


Staff. 


■ Univeraity College Hospital — Eeports of Sur- 


Council of 


gical Registrar for 1880. 8vo. Lond. 1881 


the College. 


MUSEUM. 


Thirteen Instruments designed and employed in his 




practice by the late David D. Davis, Prof, of 


Dr. 


Obstetrics, University College, London. 


Hall Davis. 


Cwt of rectal Head. 


Dr. Godson. 


Do. Do, 


Dr. Boper. 


Caste (1) showing deprePsion of parietal bone of eight 




^L months' ftstus, caused by Bticral promontory during 




^1 delivery by turning; (2) showing depreseion of 




^K parietal bone (see No 1) six months alter birth. 


Dr. S«ayue. 


^KCui of Pelvis of Dwarf 4 feet J, inch in height, who was 




^m delivered by Ca^arian Section at the Bristol 




^H Hospital (see • Obstetrical Transactions,* vol. v. 




■ p. 


Ditto. 


^H One pair straight parallel forceps ; 1 new constrictor 




^^B for the removal of uterine tumours j 4 dilators. 




^^M caoutchouc ; 4 intra-uterine pessaries ; 1 straight 


Prof. 


^^B and 1 curved uterine sound, caoutchouc. 


Laxarewitcb. 


^H VOL. XXIII. 


22